bluuebunny/crossref_metadata_2025 huggingface dataset:
Techniques and practices of Australian pest animal trappers
Authors: Meek Paul D. , Ballard Guy A. , Fleming Peter J. S.
Published: September 2018

We conducted a survey of trappers to gather baseline information on the trapping methods and humane practices used in Australia, the types of traps being used, and the attitudes of trappers. Respondents indicated that they mostly trapped wild dogs and foxes with feral cats as by-catch; rabbits were trapped to a lesser degree. Respondents favoured Jake and Victor #3 traps for the capture of wild dogs. Victor #1.5, #3 and Jake traps were also favoured for capturing foxes and feral cats. Although some trappers placed up to four traps together in a set, a single trap per set was the most commonly reported approach. Trap maintenance varied between individuals but most said they checked traps for problems during deployment. Respondents preferred the term ‘rubber jawed traps’ over the plethora of other synonyms in current use. All respondents were cognisant of animal welfare requirements but their acceptance and adoption of related trapping methods varied. Most did not believe that licensing was required to govern trapping practices in Australia. Euthanasia was most commonly undertaken by shooting the captured animal in the head, although rabbits and some non-target animals were reportedly dispatched by a blow to the head. This is the first survey of Australian trappers and provides a benchmark for understanding trapping culture, practices and practitioner expectations so these can be considered in policy development and implementation.
Kicking foot swing planes and support leg kinematics in rugby place kicking: Differences between accurate and inaccurate kickers
Authors: Bezodis Neil E. , Atack Alexandra , Willmott Alexander P. , Callard Jon E. B. , Trewartha Grant
Published: September 2018

Place kicking is a complex whole‐body movement that contributes 45% of the points scored in international Rugby Union. This study compared the kicking foot swing plane characteristics of accurate and inaccurate kickers, underpinned by differences in their support leg and pelvis kinematics at support foot contact, to identify key technique characteristics. Motion capture data (240 Hz) were collected from 33 experienced kickers, and distinct groups of accurate (n = 18) and inaccurate (n = 8) kickers were identified based on their performance characteristics. All accurate kickers were capable of kicking successfully from at least 33.3 m, whereas all inaccurate kickers would have missed left from distances greater than 30.7 m. The accurate group exhibited a moderately shallower swing plane inclination (50.6 ± 4.8° vs. 54.3 ± 2.1°) and directed the plane moderately further to the right of the target (20.2 ± 5.4° vs. 16.7 ± 4.1°). At support foot contact, the accurate group placed their support foot moderately less far behind the ball (0.08 ± 0.08 m vs. 0.12 ± 0.04 m) and positioned their centre of mass moderately further to the support leg side (0.77 ± 0.07 m vs. 0.72 ± 0.01 m) due to a moderately greater stance leg lean (29.3 ± 4.1° vs. 26.8 ± 3.2°). The kicking foot swing plane is highly planar in rugby place kicking but its orientation differs between accurate and inaccurate kickers. These plane characteristics may be controlled by support foot placement and support leg and pelvis kinematics at support foot contact.
FA05.05: PROLONGED LAPAROSCOPIC GASTRIC ISCHEMIC CONDITIONING PRIOR TO ESOPHAGECTOMY IN PATIENTS OF ESOPHAGEAL CANCER: FEASIBILITY AND CLINICAL SIGNIFICANCE
Authors: Raja Kalayarasan
Published: September 2018

Background

The studies on gastric ischemic preconditioning in improving blood flow to the distal gastric conduit and reducing the incidence of anastomotic complications have yielded variable results. Lack of adequate time interval between gastric ischemic preconditioning and esophagectomy has been postulated as one of the reasons for lack of clinical benefit. Hence the present study was done to evaluate the feasibility and clinical outcome of prolonged gastric ischemic conditioning prior to esophagectomy.

Methods

Patients with locally advanced squamous cell carcinoma of the esophagus planned for neoadjuvant chemoradiotherapy followed by esophagectomy and gastric pull through were included in the prospective study. Prior to initiation of neoadjuvant therapy laparoscopic feeding jejunostomy with ischemic preconditioning by the ligation of left and the short gastric vessel was performed. All patients underwent thoracolaparoscopic esophagectomy with two field esophagectomy and cervical esophagogastric anastomosis using modified Orringer technique. Radiological assessment of the caliber of the right gastroepiploic artery (RGEA) and Immunohistologic analysis of Hypoxia-inducible factor – 1 alpha (HIF-1alpha) expression in the fundus to determine the degree of neovascularization was performed after ischemic preconditioning. The feasibility of laparoscopic gastric mobilization post ischemic preconditioning and cervical anastomotic leak rate was documented and compared with patients who did not undergo ischemic preconditioning.

Results

Fifteen patients underwent thoracolaparoscopic esophagectomy after a median time of 124 days post laparoscopic gastric ischemic preconditioning. Minor adhesions present in the gastrosplenic region did not interfere with laparoscopic gastric mobilization. The mean pre-ischemic conditioning diameter of RGEA increased from 2.18 mm to 2.25 mm post ischemic conditioning (P = 0.21). The median HIF-1 alpha index post ischemic conditioning was 0.6. The cervical anastomotic leak rate was less in patients who underwent ischemic preconditioning (1/14, 7.1%) compared to the patients who did not undergo ischemic preconditioning (6/16, 37.5%), although the difference was not statistically significant (P = 0.24)

Conclusion

Prolonged gastric ischemic preconditioning prior to esophagectomy is safe and does not interfere with laparoscopic gastric mobilization. It can potentially reduce cervical anastomotic complications post neoadjuvant chemoradiotherapy.

Disclosure

All authors have declared no conflicts of interest.
FA06.02: OPTIMAL EXTENT OF LYMPH NODE DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Chen Long-Qi , Yang Yu-Shang
Published: September 2018

Background

The possible presence of occult tumor dissemination is the rationale of radical systematic lymphadenectomy. Theoretically, the more extent of lymphadenectomy, the more similar survival outcomes between node-negative and node-positive patients. Accordingly, there will be a certain number of examined lymph nodes (NELN) for patients with only one tumor-positive lymph node that can equal their survival with the node-negative patients, and this cut-off point should be define the minimal requirement for an adequate extent of lymphadenectomy. The aim of this report was to determine the optimal number of examined lymph nodes (NELN) dissection for esophageal squamous cell carcinoma (ESCC) by this novel method.

Methods

We retrospectively reviewed 589 ESCC patients from June 2011 and July 2012. Among them, 372 patients were pathologically confirmed with node-negative (N 0 + ), and 217 patients with only one tumor-positive lymph node (N 1 + ). Comparison of overall survival were performed using the Kaplan-Meier method. Cox regression hazard model was used for multivariate analysis to assess the independent influence of NELN on overall survival.

Results

The median survival for N 0 + and N 1 + patients was 32 versus 23 months (HR 1.61; 95% CI 22.86- 29.148; P = 0.000). Survival analyses revealed that the NELN positively correlated with overall survival (OS) both for patients with N 0- (P = 0.024) and N 1 + (P = 0.046), and an independent prognostic predictor only for N 0 + patients (hazard ratio 0.984; P = 0.032). When the cut-off point of NELN was set as a value less than 18, stratum analysis within the Kaplan–Meier method showed that NELN did not affect the results that N 1 + patients have a worse overall survival as compared with N 0 + patients (P < 0.05). However, stratum analysis showed that no significant difference in OS was observed between N 1 + and N 0 + patients when the NELN was greater than 18.

Conclusion

The NELN should be considered a mandatory requirement for improving the OS of ESCC patients. The minimum of 18 lymph nodes removed for ESCC is rational and should be complied with.

Disclosure

All authors have declared no conflicts of interest.
FA07.03: TRACHEO-BRONCHO-ESOPHAGEAL FISTULAE: THE NEW EPIDEMIC?
Authors: Gust Lucile , Trousse Delphine , Brioude Geoffrey , Dutau Herve , Doddoli Christophe , Benoit D’Journo Xavier , Thomas Pascal
Published: September 2018

Background

Acquired Tracheo-broncho-esophageal fistulae of the adult are uncommon, severe and require a complex management associating medical, endoscopic and surgical treatment.

Methods

From January 2013 to December 2017, we conducted a monocentric, retrospective study on the etiology, the diagnosis and the management of acquired tracheo-broncho-esophageal fistulae.

Results

During the last 5 years, 29 consecutive acquired tracheo-broncho-esophageal fistulae were diagnosed in our department (23 men and 6 women), of which 2 malignant fistulae. Sixteen appeared in the early postoperative period after esophagectomy (From 7 to 63 days), and two more later at post-operative day 150 and 154 days. The other 10 tracheo-broncho-esophageal fistulae had variable etiologies: post-radiation (5), traumatic (4), severe reflux. Clinical presentation were of variable severity as well. Six patients were asymptomatic, the fistula diagnosed on systematic radiological or endoscopic examinations. The other patients had respiratory and infectious symptoms, going from iterative pneumopathy to acute respiratory distress with septic shock. The management was complex and specific to each patient, but 3 situations can be described:

1. Endoscopic treatment (7)

2. Surgical treatment, more or less followed by an endoscopic treatment (7)

3. Multiple endoscopic treatment, followed by surgery (13).

Regardless of the treatment, the mortality rate was extremely high, 12 patients out of 27 dying in the early follow-up (44,4%).

Conclusion

The incidence of acquired tracheo-broncho-esophageal fistulae seems to be increasing, especially after esophagectomy. Their treatment is different than from the usual anastomotic fistula. Multimodal management is associated with patient death in about half of the cases. Endoscopic treatment allows the stabilisation of patients in a precarious clinical situation, but where the immediate results can be satisfactory it can later on lead to chronic and harmful situations. Surgery remains the cornerstone of the treatment.

Disclosure

All authors have declared no conflicts of interest.
FA07.05: VLS ONE-WAY VALVE: A MINIMALLY INVASIVE SURGERY FOR GASTROESOPHAGEAL REFLUX
Authors: Macaione Ina , Longo Antonio , Crafa Francesco , Fiorentino Eugenio
Published: September 2018

Background

Fundoplication, the standard antireflux surgery, suffers from the risks of side effects; to improve the results an alternative surgery, less invasive and more effective, was proposed by Longo. The aim of our study is to evaluate whether the technique of the ‘anterior one-way valve’ has resulted in lower complications and better functional results than total or partial fundoplication.

Methods

Between 2004 and 2009, 70 patients were operated with the Longo technique in Vienna. The technique consists of the transversal invagination of the anterior gastric wall: from the Z line to 8–10 cm caudally and from the lesser curvature to the angle of His. An anti-reflux valve, dome-shaped, is obtained on the cardias. An anterior hiatoplasty is added in case of diaphragmatic hiatus dilatation. The one-way valve impedes the reflux and at the same time it doesn’t cause gas-bloat syndrome or dysphagia. Moreover, the technique pulling down the esophagus in the abdominal cavity, prevents the hiatal hernia relapse.

Results

No patient required redo-surgery, presented a gas-bloat syndrome in the perioperative phase and after a long interval, neither symptoms of dysphagia at long terms. All the patients showed a general improvement in QoL up to 40.3%. The intervention reduced esophageal acid exposure and the esophagitis improved in all the patients. Patients with GERD recurrence at 5 years showed in 1 case grade B esophagitis and in 2 cases injuries attributed to grade A.

Conclusion

The technique of the anterior one-way valve creates a one-way valve system without any interference on the dynamics of the LES, allowing both the relaxation after swallowing, with almost no postoperative dysphagia, and TLESR with inherent possibility of belching and vomiting. The results are effective on the general state of health of the patients and on the objective check of gastroesophageal reflux endoscopically detected. The advantages of this new approach are made evident by the simplicity and speed of the operation associated with a mortality rate of 0%, low morbidity, no gas bloat syndrome or dysphagia.

Disclosure

All authors have declared no conflicts of interest.
FA07.06: PERSISTENT DYSPHAGIA IS A RARE PROBLEM AFTER LAPAROSCOPIC NISSEN FUNDOPLICATION
Authors: Nikolic Milena , Schwameis Katrin , Semmler Georg , Asari Reza , Semmler Lorenz , Steindl Ariane , Mosleh Berta , Schoppmann Sebastian
Published: September 2018

Background

Although around 30% of patients with gastroesophageal-reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF).

Methods

Out of a prospective patients database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients overall satisfaction.

Results

After a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR, 0–4.3) vs. 19 (IQR, 17–32); P < 0.000) and the median alimentary satisfaction (AS) was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow up, whereas 4% of the patients reported irregular PPI-use.

Conclusion

LNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared.

Disclosure

All authors have declared no conflicts of interest.
FA08.03: PREOPERATIVE SARCOPENIA INFLUENCES THE RISK OF POSTOPERATIVE PNEUMONIA IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: Tamura Tatsuro , Sakurai Katsunobu , Toyokawa Takahiro , Kubo Naoshi , Amano Ryosuke , Tanaka Hiroaki , Muguruma Kazuya , Yashiro Masakazu , Maeda Kiyoshi , Hirakawa Kosei , Ohira Masaichi
Published: September 2018

Background

Exact measurement of muscle mass is enabled by body composition analyzer, and it is reported that a body composition affects the perioperative outcomes. In this study, we investigated the relationship between depletion of preoperative muscle mass (sarcopenia) and postoperative outcomes in patients with esophageal cancer treated esophagectomy.

Methods

A total 58 esophageal cancer patients who underwent esophagectomy between January 2014 and January 2018 were enrolled. Preoperative muscle mass was evaluated by InBody-3.0 and S-10 which is body composition analyzer and expressed as muscle mass index; MMI (kg/m2) by dividing the muscle mass by the height in meters squared. The cut off values of MMI were the gender-specific lowest 20%, and we defined low MMI as sarcopenia. Postoperative complications were graded according to the Clavien-Dindo classification, univariate and multivariate analysis were performed for postoperative pneumonia. About the pneumonia, we defined that invasive shadow was observed by X-ray or CT and bacteria detected by sputum culture.

Results

By the definition of sarcopenia in this study, sarcopenia was determined in 11 patients (19%). Sarcopenia was significantly correlated with lower body weight (P < 0.001), lower body mass index (P < 0.001), the VC% (P = 0.0178). In other factors, there is no significant difference between sarcopenia and non-sarcopenia groups. Compared with non-sarcopenic patients, sarcopenic patients had a higher risk of postoperative pneumonia and chylothorax (P = 0.0144 and P = 0.0105). For other complications, the differences were not significant. In univariate analysis, sarcopenia (P = 0.0144), hypoalbuminemia (P = 0.0236), operative blood loss (P = 0.0436) were associated with postoperative pneumonia. Multivariate analysis revealed that sarcopenia (P < 0.001) and longer operation time (P = 0.0354) were independent predictors of postoperative pneumonia.

Conclusion

Preoperative sarcopenia was identified as independent risk factor for postoperative pneumonia after esophagectomy. Preoperative nutrition and rehabilitation therapy may contribute to the prevention of pneumonia after surgery.

Disclosure

All authors have declared no conflicts of interest.
FA08.04: RELATIONSHIP BETWEEN PROGNOSTIC NUTRITIONAL INDEX AND PERITUMORAL IMMUNE SYSTEM DYNAMICS IN ESOPHAGEAL CANCER
Authors: Okadome Kazuo , Baba Yoshifumi , Yagi Taisuke , Kiyozumi Yuki , Daisuke Kuroda , Sawayama Hiroshi , Hiyoshi Yukiharu , Iwatsuki Masaaki , Miyamoto Yuji , Yoshida Naoya , Baba Hideo
Published: September 2018

Background

There have been reported that nutritional status and tumor-infiltrating lymphocytes (TILs) are prognostic factor for esophageal cancer. Prognostic Nutritional Index (PNI) is one of the most widely used indicators for nutritional status and also shows systemic immune competence. Because TILs is related to peritumoral immune system, there may be relation between PNI and TILs.

Methods

Using a database of 300 curatively resected esophageal cancer from April 2005 to Jun 2013, we evaluated the relationship between PNI and TILs. PNI was calculated using serum albumin and total lymphocyte count. TILs were histologically estimated using postoperative samples. Studying the expression of CD8 and Foxp3 by immunohistochemical staining, we tried to reveal which subsets of lymphocyte were relevant to PNI.

Results

PNI high group (N = 198) experienced better overall survival (P < 0.001) and cancer specific survival (P < 0.001) compared with PNI low group (N = 102). PNI was significantly related to the TILs status (P < 0.01). CD8 positive lymphocyte was also significantly related to the PNI (P = 0.013) but Foxp3 wasn’t (P = 0.62). CD8 positive lymphocyte high group (N = 224) was significantly better in overall survival (P = 0.028) and cancer specific survival (P = 0.012) than low group (N = 76). There was no significant difference between Foxp3 high group (N = 225) and Foxp3 low group (N = 75) about overall survival (P = 0.87) and cancer specific survival (P = 0.90).

Conclusion

PNI was predictive prognostic marker for esophageal cancer and had relation to TILs status. It means systemic immune competence maybe affects peritumoral immune system. Among subsets of lymphocyte, CD8 positive lymphocyte had relation to PNI and was prognostic factor. In this study, Foxp3 didn’t have any relation to PNI and prognosis.

Disclosure

All authors have declared no conflicts of interest.
PS01.025: CONSEQUENCES OF MUCOSAL PERFORATION FROM LAPAROSCOPIC HELLER MYOTOMY: A SYSTEMATIC REVIEW
Authors: Maurice Andrew , Malik Hassan , Pearson Thomas , Dodd Benjamin
Published: September 2018

Background

Mucosal perforation is a common complication of Laparoscopic Heller Myotomy (LHM) for achalasia. Perforations discovered intra-operatively are usually treated with laparoscopic suturing. Perforations not identified at the time of operation generally present with sepsis and a leak. We aimed to document every reported case of mucosal perforation in the literature following this procedure and define the prognostic significance of this complication.

Methods

A systematic literature search was performed using the PubMed database with the key-phrases ‘achalasia’ and ‘laparoscopy’ or ‘laparoscopic’. All English-language case series and trials were included that reported at least one mucosal perforation from 1997 to 2017. Two researchers appraised the literature for inclusion. For centers with multiple publications, the largest series was chosen for inclusion.

Results

Of 901 articles retrieved, 100 studies were included after duplicates were excluded. 672 mucosal perforations were reported in 8705 LHM procedures (7.7%, range 0.5–30%).

635 perforations were identified intra-operatively. 609 (96%) were repaired with laparoscopic suturing with or without fundoplication and no clinical sequelae. 22 (3.5%) were converted to open procedures. No deaths or long-term morbidity was reported in procedures where perforations were identified intra-operatively.

There were 37 definitive missed mucosal perforations that were identified post-operatively. 3 patients died. For those that survived, 22 returned to theatre, 2 were treated with radiological drainage and 10 were managed conservatively with long-term antibiotics. Due to differences in reporting nomenclature and definitions, the actual rate of missed mucosal perforations may be higher.

Conclusion

Mucosal perforation during LHM is rarely of prognostic significance if it is repaired with laparoscopic suturing at the time. Mucosal perforations identified post-operatively can result in re-operation, sepsis, prolonged hospital stay and death. Care should be taken to ensure any mucosal perforation is detected and repaired intra-operatively.

Disclosure

All authors have declared no conflicts of interest.
PS01.028: REOPERATIONS AFTER FAILED HELLER´S MYOTOMY FOR ESOPHAGEAL ACHALASIA
Authors: Roque González Rosalba , Angel Martínez Miguel , Gerardo Pereira Jorge , Jiménez Raul , Anido Vivianne , Neri Pinol Felipe
Published: September 2018

Background

Heller's cardiomyotomy associated with the anti-reflux procedure described by Dor is the treatment of choice in patients with esophageal achalasia. However, the causes of treatment failure are still controversial. The primary aim of this study is to describe the causes of failure of Heller's myotomy in patients operated on due to esophageal achalasia and the clinical progress of patients who required another surgery.

Methods

A descriptive, retrospective and longitudinal study of a series of patients who required another surgery due to failure of Heller's myotomy from January 2010 to December 2016.

Results

Heller's myotomy was performed in 253 patients diagnosed with esophageal achalasia. Of these patients, 7 (2.7%) required another surgery due to recurrence of symptoms, 4 (1.5%) were initially operated on at the institution and the rest were referred from other institutions in the country. Laparoscopic approach was utilized in 5 patients and 2 were treated thoracoscopically. The mean age was 41 ± 15 years (range 20–59). The most frequent symptoms were postoperative dysphagia and weight loss (100%). The time of recurrence of symptoms after the first operation was 6–12 months in 4 patients (57%), 12 to 18 months in 1 (16%) and 18 to 24 in 2 (33%) patients.

Conclusion

Incomplete myotomy was the main cause of reoperation, with laparoscopic re-myotomy with or without fundoplication being the surgical technique of choice for these patients, who had an excellent or good postoperative clinical progress.

Disclosure

All authors have declared no conflicts of interest.
PS01.035: ILEOCOLONIC INTERPOSITION GRAFT: A SAFE AND FEASIBLE CONDUIT AFTER ESOPHAGOGASTRECTOMY
Authors: Voon Kelvin , How Teoh Keat , Subramaniam Karthikeashvaren , Yee Lim Shyang , Nagalingam Premnath
Published: September 2018

Background

Restoration of gastrointestinal tract continuity with a suitable conduit is a vital step in esophagectomy. An adequate length of conduit, preservation of a good blood supply and functionality are keys to a successful outcome

Methods

We report two cases of successful ileocolonic interposition graft after esophagogastrectomy for caustic injury.

Results

Both patients were female with mean age of 45. They presented with progressive dysphagia and weight loss after alleged corrosive ingestion. Both had good functional status with no significant comorbidities. OGDS revealed long complex esophageal stricture and biopsy showed acute on chronic esophagitis. CT scan showed diffuse thickening of mid-distal esophagus and gastric stenosis. Both patients had refractory strictures with unsuccessful serial endoscopic dilatation. One patient had endoscopic nasoenteric tube insertion for enteral feeding while the other had laparoscopic feeding jejunostomy placed due to tight strictures. A 3-stage esophagogastrectomy with ileocolonic interposition graft was performed after optimization. Intra-operatively findings were dense fibrotic esophagus with diffuse gastric strictures. Ileocolonic graft comprising of the distal 15cm of terminal ileum, ascending colon and transverse colon was constructed based on middle colic arterial supply via marginal artery of Drummond. Vascularity and length of graft were confirmed before transection. Graft pull through was done via orthotopic posterior mediastinal route and isoperistaltic end-to-side esophago-ileocolonic anastomosis was performed at the neck. Contrast studies showed no anastomotic leak and both patients were discharged well on postoperative day 10. They had good oral intake with satisfactory weight gain with no functional disorders during follow up.

Conclusion

Ileocolonic interposition graft is a safe and feasible option if a gastric conduit is not available. In addition to the advantages of long length, reflux resistance and good blood supply, the smaller caliber of the ileum eases the pull through and the anastomosis due to a smaller size discrepancy.

Disclosure

All authors have declared no conflicts of interest.
PS01.038: MANAGING POST STENT LARGE TEF FOR BOERHAAVE SYNDROME: A THERAPEUTIC CHALLENGE
Authors: Chandramohan Servarayan , Varadharajan Visvarath , Chinnathambi Madeshwaran , Manickavasagam Kanagavel , Chandramohan Apsara
Published: September 2018

Background

Stenting of Boerhaave syndrome is accepted as a modality of therapy but may not be successful at all times. We report a case of failed stenting, restenting and TEF due to stent.

Methods

This patient was managed at a different center and has undergone multiple procedures before. We have listed the procedures in chronological order. 24 FEB 2017: Endoscopy for acute retrosternal pain 28 FEB 2017: Left ICD for pyothorax 4 MARCH 2017: 15cm PTFE covered stent for large oesophageal rent at 28 cm 3 APRIL 2017: Stent removal 4 APRIL 2017: Check CT scan oesophago pleural fistula with 3mm rent on lelft lateral wall 8 APRIL 2017: Fistula closure with APC and fibrin sealant. 12 APRIL 2017: Fistula closure done with Thermal coagulation glue and covered SEMS. 27 MAY 2017: Stent removal and check ct showed supracarinal TEF admitting the scope. REFERED TO OUR UNIT AT THIS STAGE.

Results

Procedure done at our center: Right thoracotomy, layered fistula closure and vascularised intercostal muscle flap, subtotal esophagectomy, retrosternal gastric pullup, oesophago gastric anastamosis with feeding enteral access.

Conclusion

Post operative period was uneventful. Tracheostomy was done on 4th POD as there was drop in oxygen saturation. He improved gradually. Oral fuid started on day 7. Discharged on day 16. He is on regular followup.Tracheostomy and jejunostomy tubes removed. He was eating and speaking normally. This case is presented to high light the pertinent issues and limitations of SEMS placement for oeosphageal perforation. Diligent approach is to be followed in cases presenting with large diameter perforations. Caution should be exercised in SEMS exchange procedures when primary stenting has not produced optimal results. Surgery in select situations can be an optimal solution in these patients.

Disclosure

All authors have declared no conflicts of interest.
PS01.052: OUR STANDARD PROCEDURE IN LAPAROSCOPIC NISSEN FUNDOPLICATION FOR GERD PATIENTS
Authors: Suwa Tatsushi , Kitamura Kenta , Matsumura Tomonori , Karikomi Kazuhiro , Koyama Motoi , Okada Keigo , Suzuki Hiroyuki , Masamura Shigeru
Published: September 2018

Background

Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated by many surgeons. We have established our simple procedure.

Methods: SURGICAL PROCEDURE

Setting Our 5-trocar setting with patients is as follows: 12 mm trocar just below the navel (A), 5 mm trocar at the upper right abdomen for pulling up lateral segment of the liver, 5 mm trocar at the upper right abdomen, 12 mm trocar at the upper left abdomen (B), 5 mm trocar at the middle left abdomen (C). Step 1 Under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus of the diaphragma has been dissected free from the soft tissue around the stomach. In this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid unnecessary bleeding. After cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. Then the inside margin of the left crus of the diaphragma was recognized from right side. In this part, laparoscope: trocar (A), the assistant: trocar (B), the operator's right hand: trocar (C). Step 2 The branches of left gastroepiploic vessels and the short gastric vessels were divided. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. In this part, laparoscope: trocar (A) at the beginning of dividing left gastroepiploic vessels, trocar (B) when dividing short gastric vessels. Step 3 The both crus are sutured with interrupted stitches to reduce the hiatus. From the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. Then the fundus of the stomach is pulled to obtain a 360 degree ‘stomach-wrap’ around the abdominal esophagus. Using 2–0 non-absorbable braided suture, stitches are placed between both gastric flaps.

Results

We have performed this procedure in 90 cases. The mean operation time of recent 20 cases was 90 min.

Conclusion

We have established our standard anti-reflux surgery procedure with less bleeding and less operative time.

Disclosure

All authors have declared no conflicts of interest.
PS01.053: GASTRO-ESOPHAGEAL REFLUX TEST DECIDING SURGICAL INDICATION AND RESULTS OF LAPAROSCOPIC NISSEN FUNDOPLICATION FOR GERD PATIENTS
Authors: Suwa Tatsushi , Kitamura Kenta , Matsumura Tomonori , Karikomi Kazuhiro , Koyama Motoi , Okada Keigo , Suzuki Hiroyuki , Masamura Shigeru
Published: September 2018

Background

The indication of laparoscopic anti-reflux surgery for GERD patients is difficult to be judged fairly. We have established ‘Reflux Test‘ as the tool for the decision in the surgical indication for GERD patients.

Methods

Reflux Test At the standing position a patient swallows 300 ml barium solution. After total solution goes into stomach, a patient lies down at the flat position. Then a patient changes the position to left lateral decubitus position, flat position, right lateral decubitus position and flat position again every 10 seconds in the order. During this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. If the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. If the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. The anti-reflux surgery was considered in the moderate and severe categories.

Results

We have performed laparoscopic Nissen procedure in 90 cases. The mean operation time of recent 20 cases was 90 min. The outcome was assessed by Reflux Test performed on 4–5 postoperative day, and the results showed no reflux in every cases. Median follow-up period of this study was 48 months (0–99 months). In 11 cases (12.6%) PPI was restarted before 6 months after the anti-reflux surgery. In 23 cases (25.6%) PPI was restarted after the anti-reflux surgery during the whole follow-up period of this study. The BMI of the patients had no relationship to the needed PPI restart. To evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed ‘the esophagitis score’. In this scoring method, a number from 0–5 was assigned according to the degree of esophagitis along with the LA classification. The results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the PPI restarted group (P < 0.001).

Conclusion

Reflux Test is feasible because of its convenience and visual effects for the patients. The results of the laparoscopic Nissen fundoplication were good and satisfied by the patients mostly.

Disclosure

All authors have declared no conflicts of interest.
PS01.062: REFLUX ASPIRATION SURGICAL OUTCOMES: DOES LAPAROSCOPIC FUNDOPLICATION SIGNIFICANTLY DECREASE QUANTITATIVE AND SYMPTOMATIC PULMONARY ASPIRATION?
Authors: Khoma Oleksandr , Falk Susanna , Burton Leticia , Van Der Wall Hans , Falk Gregory
Published: September 2018

Background

Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested.

Methods

Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data was analysed.

Results

Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (P = 0.002) and pharynx supine and upright (P = 0.027) was confirmed on scintigraphy post operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459–95.194; P = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 90.5, SD 18.8), modest improvements at 6 months (mean 92.8, SD 23.9) and 12 months (mean 92.2, SD 27), were not significant (P = 0.07).

Conclusion

Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery. Overall satisfaction with surgery in patients with pulmonary aspiration is inferior compared to other patients undergoing anti-reflux surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.063: THE EFFECT OF DISEASE DURATION ON SURGICAL OUTCOMES FOR PATIENTS WITH EROSIVE GERD TREATED BY LAPAROSCOPIC SURGERY
Authors: Tsuboi Kazuto , Omura Nobuo , Yano Fumiaki , Hoshino Masato , Yamamoto Se-Ryung , Akimoto Shunsuke , Masuda Takahiro , Kashiwagi Hideyuki , Mitsumori Norio , Yanaga Katsuhiko
Published: September 2018

Background

Erosive gastro-esophageal reflux disease (e-GERD) is associated with various symptoms caused by reflux of acid and gastric contents from the stomach to the esophagus. In general, it seems that as the duration of the disease is longer, surgical outcomes are inferior because of disease progression. The aim of this study is to evaluate the relationship between the disease duration and surgical outcomes of laparoscopic fundoplication (LF).

Methods

Two hundred and fifty-one (mean age was 53.4 years, male in 166) patients with e-GERD who underwent LF as an initial operation at our institution were extracted from the database. E-GERD was defined as equal to or more than grade A esophagitis by Los Angeles classification. These patients were divided into three groups by the length of disease duration: less than two years in Group A (n = 104), two to 5 years in Group B (n = 68) and equal to or more than 5 years in Group C (n = 79). We analyzed patients’ background, pre-operative symptoms, surgical outcomes, patients’ satisfaction and post-operative course. Before surgery, a standardized questionnaire was used to assess the degree of frequency and severity of symptoms (heartburn, regurgitation, dysphagia, vomiting and chest pain). Moreover, satisfaction with the operation was evaluated using the standardized questionnaire.

Results

Age and degree of acid reflux by pH-metry were significantly different among the three groups (P = 0.0054 and 0.0345, respectively). As to the pre-operative symptom score, the severity score of heartburn and the frequency score of regurgitation were significantly lower in Group A (P = 0.0225 and 0.031, respectively). Although operation time was significantly difference among the three groups (P = 0.0423), there were no differences in intraoperative blood loss, occurrence of peri-operative complications, post-operative course and patients’ satisfaction.

Conclusion

Although the patients who suffered equal to or over two years had more severe heartburn and regurgitation because of prolonged acid reflux, the duration of the disease does not seem to affect the surgical outcomes.

Disclosure

All authors have declared no conflicts of interest.
PS01.067: SHLYAKHOVSKIY I.A., ERMOLOVA I.V., SELINA I. E., P. O., BURCHULADZE/PERFORATED APPENDICITES IN DIAPHRAGMAL HERNIA
Authors: Shlyakhovskiy Igor
Published: September 2018

Background

We present a clinical case of a patient with acute perforated appendicitis complicated by empyema in a false left-sided diaphragmatic hernia.

Methods

Patient K. 21 L. taken by ambulance to the intensive care unit. X-ray conclusion—the rupture of the left dome of the diaphragm to the infringement of the colon. The patient urgently operated. The defect of the diaphragm size 10,0х6,5cm. There is a lack in the abdominal cavity of small and large intestine, and spleen. The diagnosis—gangrenous perforated appendicitis in the left pleural cavity, empyema. Performed appendectomy, diaphragm was sutured. 5 days after surgery performed videothoracoscopy

Results

The patient is in satisfactory condition was discharged from hospital 32 days after admission.

Conclusion

Polypositional x-ray examination of the chest and abdominal cavity and active surgical tactics has allowed to establish the correct diagnosis and resulted in a favorable outcome.

Disclosure

All authors have declared no conflicts of interest.
PS01.082: ESOPHAGEAL PERFORATIONS: WHAT TO DO?
Authors: Caballero Albert , Viciano Marta , Garsot Elisenda , Arnau Marta , Francesc Julian Joan
Published: September 2018

Background

Esophagus perforations are one of the most severe lesions of the digestive tract. Until now the treatment continues to be controversial, with mortality greater than 30% of cases, mainly with a thoracic location. Severity is determinate by the progression of infection due to anatomical characteristics of the mediastinum. The location, size of the perforation and the evolution time determine the treatment to follow. In order to assess the results obtained and the different management options we present a series of 9 patients, with benign esophageal perforations, treated in our center during the last 5 years.

Methods

We designed an observational study in which we identify retrospectively the results of our series during the last five years (From 2013 to 2018). We analysed the following variables: Characteristics of patients, medical and surgical management, morbidity and mortality

Results

In all series, 5 of 9 patients received surgical treatment (55,5%), In the remaining three cases, simple suture and placement of drainages was performed. Conservative treatment was the first management attempt in the last four cases (44,5%), all of them due to impaction of food bolus or foreign body. Of all series evolved favourably with a non-negligible morbidity and continued ambulatory follow up. There was no mortality.

Conclusion

It is difficult to establish a protocol of action in patients with esophageal perforation. We have obtained good results by individualizing each case and adjusting the type of treatment to the needs of each patient, from a conservative attitude to radical surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.084: BOERHAAVE SYNDROME: CONTINUING CHALLENGE TO TREATMENT
Authors: Chandramohan Servarayan , Varadharajan Visvarath , Chinnathambi Madeshwaran , Manickavasagam Kanagavel , Chandramohan Apsara
Published: September 2018

Background

Boerhaave syndrome produces an extremely severe clinical profile due to extravasation of digestive secretions and food into the mediastinum and pleural space. Diagnosis is often delayed, since it is a rare disease and is usually confused with other equally serious pathologies. These factors contribute to its high mortality rate. We present a case which was previously treated in three different institutions and finally referred to our department.

Methods

81 year old gentleman was diagnosed as Boerhaave syndrome on 23rd Jan 2017. He had treatment in three different institutions: right ICD in first center: feeding jejunostomy and venting gastrostomy in second center: over the scope clipping and hemoclip in third center. As he continued to have persistent leak of enteral contents and purulent discharge in ICD, he was referred to our department for further management, two months after the intial insult.

Results

Patient was optimised for surgery and transhiatal esophagectomy with esophago gastric anastomosis was done in our department. Operative findings: Abdomen entered through midline incision, hiatal peritoneum incised, gastro esophageal junction encircled and esophagus mobilised. It revealed purulent discharge from right hemithorax and a 4cm esophageal perforation along right lateral aspect of esophagus above GE junction.About 120ml of foul smelling pus drained. Considering unhealthy esophageal tissue, long rent and failed endotherapy it was decided to do transhiatal esophagectomy. Previous gastrostomy site closed in 2 layers with 3–0 PDS. Through left anterior sternomastoid incision cervical esophagus mobilised and transected at low neck level and the specimen was removed through the hiatus. A gastric tube was made with linear staples and brought into neck through posterior mediastenum by camera sheath technique. Esophago-gastric anastamosis completed with posterior stapled and anterior hand sewn technique. Post op period was uneventful.

Conclusion

Early diagnosis and appropriate therapeutic strategies can reduce the mortality rate of Boerhaave's syndrome. Early intervention reduces the morbidity and mortality. The mortality increases with increasing time post insult. our patient who had undergone multiple theraputic modalities in three different centers was succesfully managed with trans hiatal esophagectomy in our department.

Disclosure

All authors have declared no conflicts of interest.
PS01.095: BENIGN ESOPHAGEAL STRICTURE: A RECAP OF OUR EXPERIENCE
Authors: How Teoh Keat , Voon Kelvin , Yee Lim Shyang , Nagalingam Premnath
Published: September 2018

Background

Caustic injury remains the commonest cause of benign esophageal strictures in Asia. Others include gastroesophageal reflux, iatrogenic, radiation, autoimmune or idiopathic causes. Treatment goals are relief of dysphagia and prevention of recurrence. This study aims to evaluate the experience with benign esophageal stricture in Penang Hospital, a tertiary hospital in Northern region of Malaysia.

Methods

A retrospective review of 12 patients with benign esophageal strictures between year 2012 - 2017.

Results

The mean age was 53.5 and two thirds were female. Half of these patients were of Chinese ethnicity while the other half were Indian. The commonest cause was caustic ingestion (41.7%), followed by reflux stricture (25%) and anastomotic stricture (25%). There was one case of dystrophic epidermolysis bullosa. More than half of the patients had complex and multiple strictures. 41.7% of patients had proximal strictures that were located within 20cm from the incisors. Endoscopic dilatation was the first line treatment with either Savary Gilliard or balloon dilators. A total of 97 dilatation sessions were done with a mean dilatation frequency of 2.3 ± 1.5 times for anastomotic strictures, 8 ± 8.2 times for reflux strictures and 8.0 ± 6.6 times for corrosive strictures. The mean dilatation interval was 2.5 ± 1.2 weeks. 58.3% of patients had successful endoscopic treatment. The success rate was higher in non-corrosive stricture (83% vs 40%). There was one dilatation related complication in which the patient had pneumomediastinum without overt mediastinitis. This however, resolved with conservative management. 41.7% of patients had refractory strictures that failed endoscopic dilatation. Surgery including esophagectomy (40%), revision of anastomosis (20%) and gastrostomy (40%) were done for this group of patients. Proximal strictures, complex strictures and multiple strictures were associated with failed endoscopic dilatation (P < 0.05).

Conclusion

Endoscopic dilatation is the first line treatment for benign esophageal strictures. Surgery is reserved for refractory strictures with failed endoscopic treatment. Predictor scoring systems for refractory stricture and individualized approaches are the key to success.

Disclosure

All authors have declared no conflicts of interest.