Systematic review of the results of fenestrated endovascular aortic repair in octogenarians

INTRODUCTION

With the increasing life expectancy of Western populations, more octogenarians are presenting with large abdominal aortic aneurysm (AAA). Endovascular repair offers a less invasive alternative and older patients who may not have been offered open repair in the past are now being considered for elective repair with this approach. Age in isolation may not be the only consideration in recommending elective aneurysm repair. We aimed to review the literature on complex endovascular AAA repairs (mainly fenestrated endovascular aortic repair [FEVAR]) in octogenarians.

METHODS

A literature search was conducted using the Ovid Medline®, Embase® and Cochrane Library databases for articles published up to January 2022. All English language publications from 1995 onwards were eligible for inclusion. Search terms included: "FEVAR", "F-EVAR", "fenestrated EVAR", "fenestrated endovascular aortic repair", "fenestrated endovascular aneurysm repair", "fenestrated AAA repair", "fenestrated endograft", "fenestrated stent graft", "fenestrated", "endograft", "EVAR", "octogenarian", "elderly", "above 80" and "over 80".

METHODS

The literature search identified 134 potential articles. Following qualitative assessment by two independent appraisers, this was refined to 11 studies, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement.

RESULTS

The primary outcome measure was 30-day mortality, which was highly variable, ranging from 0% to 9% in octogenarians and from 0% to 5% in non-octogenarians. However, these differences were only found to be statistically significant in two studies. The secondary outcome measures included technical success rates, major adverse events, reintervention rates, freedom from reintervention, target vessel patency, freedom from target branch instability, and length of hospital and intensive care unit stay. No statistically significant differences were found between octogenarians and non-octogenarians. Long-term survival was significantly lower for octogenarians in two studies.

CONCLUSIONS

The perioperative outcomes of FEVAR in octogenarians are comparable with those of younger patients. FEVAR therefore appears to be an acceptable option for complex endovascular aneurysm repairs in carefully selected octogenarians. Nevertheless, this review highlights the paucity of published data on the outcomes of endovascular repair of complex aneurysms in octogenarians.

SP7.2.5 Robotic incisional/ventral hernia repair is feasible approach compared to laparoscopic repair: a systematic review

Aims

Robotic incisional/ventral hernia repair (R-IVHR) is gaining popularity due to higher safety as well as feasibility profile. The objective of this study is to present a systematic review exploring the role of robotics compared to laparoscopic approach in the management of incisional/ventral hernia.

Methods

A systematic review of all types of comparative studies until January 2021 published on Embase, Medline, PubMed, PubMed Central and Cochrane databases reporting the clinical outcomes in patients undergoing either R-IVHR versus Laparoscopic (L-IVHR) was performed.

Results

A total of 8289 patients in 7 studies were included. There was minimal heterogeneity (Tau2 = 0.29, chi2 = 9.10, df, I2 = 45 %) among included studies for the variables of recurrence rate and post-operative complications, but statistically significant heterogeneity (Tau2 = 1.05, chi2 = 132.81, I2 = 96 %) was observed for the duration of operation. In the random effects model analysis using the statistical software Review Manager, statistically the R-IVHR prolonged the duration of operation (Standardized mean difference, 2.24; 95% CI, 1.37, 3.11; z = 5.06; P = 0.00001) but the post-operative complication rate (OR 0.63; 95% CI, 0.30, 1.34; z = 1.20; P = 0.23) as well as the recurrence rate (OR 0.63; 95% CI, 0.14, 2.74; z = 0.62; P = 0.53) were similar.

Conclusion

R-IVH repair is feasible and safe, but the duration of operation is significantly longer. Major multi-center randomized controlled trial is mandatory to assess the long terms outcomes and cost effectiveness before the routine use of R-IVHR.

EP.WE.859Pain management in critical limb ischaemia patients: a clinical audit

Aims

Critical Limb Ischaemia (CLI) patients often present with ischaemic rest pain and uncontrolled pain can impact on quality of life. To improve pain control, a set a of trust-wide guidelines were developed to standardise pain management for CLI patients.

Methods

This was a prospective cross-sectional audit, which initially involved 30 patients admitted under vascular surgery at a tertiary centre with CLI between May and June 2020. The improvements implemented included an analgesia education session for junior doctors, inclusion of an analgesia dosing table in the vascular clerking proforma and a simplified analgesia table as a poster. The re-audit included 22 patients with CLI between September and October 2020. Data was collected from drug charts and Fisher’s exact test was used for the statistical analysis.

Results

Baseline data suggested poor compliance with guidelines with only 3% of patients prescribed the guideline recommended PRN opiate doses. This improved post-intervention to 52% (p < 0.05). Following the interventions, naloxone prescribing significantly improved from 37% to 91% (p < 0.05). Standard dosing of opiates was seen irrespective of age or renal function. 14% of patients with renal impairment were prescribed opiate analgesia above the initial ranges indicated by the guidelines; compared to 33% in the first cycle (p = 0.58).

Conclusion

This audit has demonstrated the successful implementation of targeted changes to improve compliance with trust pain management guidelines for patients with CLI. The challenge remains of overcoming the unknown eGFR at time of prescription and unknown background analgesia that can lead to over and under prescribing.

Intraperitoneal local anaesthesia for post-operative pain management in patients undergoing laparoscopic colorectal surgery: a systematic review and meta-analysis

INTRODUCTION

Intraperitoneal instillation of local anaesthetic agents has been reported as an effective adjunct to pain management and early functional recovery in colorectal surgery. Laparoscopic colorectal resection (LCR) is considered as the gold standard approach to resect benign and malignant lesions of the colon and rectum due to the advantages of reduced pain score, quicker recovery, and shorter hospitalization. The objective of this study is to systematically analyze the published RCTs evaluating the effectiveness of intraperitoneal local anesthetic (IPLA) instillation versus standard analgesia in patients undergoing LCR.

EVIDENCE ANALYSIS

Electronic databases such as Embase, Medline, PubMed, PubMed Central and the Cochrane library pertaining to the use of IPLA infiltration after LCR were systematically reviewed using the principles of meta-analysis.

EVIDENCE SYNTHESIS

Five RCTs on 292 patients undergoing LCR were either given IPLA or standard post-operative analgesia. In the random-effects model analysis using the statistical software Review Manager, statistically 2-4 hours pain score (Standardized mean difference (SMD), -1.72; 95% CI, -2.62, -0.81; z = 3.71; P = 0.0002) was significantly ower in the IPLA group. The 12 hours post-operative pain score (P = 0.23) was also lower in the IPLA group but failed to reach the statistical significance. Opioid analgesia requirement was lower in the IPLA group (SMD -7.60; 95% CI, -11.21, -3.90; z = 4.12; P = 0.0001) but the time to flatus, length of stay and the frequency of nausea/vomiting were statistically similar in both groups.

CONCLUSIONS

IPLA instillation is an effective modality to reduce the post-operative pain score and lower the opioid analgesic requirements in patients undergoing LCR without influencing the time to first flatus, length of stay, and post-operative nausea/vomiting.

56 Antibiotic Prescribing for Open Fractures - A Quality Improvement Project to Enhance BOAST 4 Attainment

Introduction

Open fractures are associated with increased infection rates and the evidence shows timely administration of prophylactic antibiotics within one hour of injury improves the outcomes.

Method

A multi-cycle audit was carried out retrospectively for patients presenting to Brighton and Sussex University Hospitals NHS Trust (BSUH) with an open limb fracture in 2018-2020. Targeted teaching was carried out for orthopaedic trainees, prompt posters created and alterations to the trauma clerking proforma were implemented.

Results

In first cycle, 48 (92.3%) out of total 52 patients were prescribed antibiotics prior to definitive surgical management, with a mean time to administration of 271 minutes. Of these, 41 (78.8%) received prescriptions according to BSUH guidelines. The use of STAT ‘once-only’ prescriptions was found to significantly reduce the mean time to administration for 154 minutes. In second cycle, all of 29 patients (100%) were prescribed antibiotics prior to definitive surgical management, with a reduced mean time to administration (233 minutes). Of these, 26 (89.7%) received prescriptions according to BSUH guidelines, and a significantly greater proportion received initial STAT prescriptions (51.7% vs. 15.4%).

Conclusions

This quality improvement project has demonstrated the successful implementation of targeted changes to improve the attainment of BOAST 4 guidelines.

Epigastric port retrieval of the gallbladder following laparoscopic cholecystectomy is associated with the reduced risk of port site infection and port site incisional hernia: An updated meta-analysis of randomized controlled trials

Aims

The objective of this article is to compare the surgical outcomes for epigastric port or umbilical port retrieval of the gallbladder (GB) following laparoscopic cholecystectomy (LC).

Methods

The data retrieved from the published randomized, controlled trials (RCT) comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC was analysed using the principles of meta-analysis. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR).

Results

Eight RCTs on 2676 patients comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the GB retrieval through epigastric port was associated with the reduced duration of operation (SMD, 0.41; 95% CI, 0.18, 0.64; z = 3.52; P = 0.0004). Epigastric retrieval was also associated with reduced risk of surgical site infection (OR, 1.95; 95% CI, 0.75, 5.11; z = 1.36; P = 0.17), and port site incisional hernia (OR, 4.22; 95% CI, 0.43, 41.40; z = 1.24; P = 0.22) compared to umbilical port retrieval though it did not reach statistical significance. The need for port enlargement to retrieve the GB was similar in both groups. In contrast, the umbilical port retrieval of the GB was associated with significantly less post-operative pain (SMD, −0.51; 95% CI, −0.95, −0.06; z = 2.24; P = 0.03), reduced GB perforation rate, reduced port site bleeding rate and reduced difficulty in GB retrieval.

Conclusion

GB retrieval through epigastric port following LC has clinically proven advantage of reduced retrieval site infection rate, lower operation time and incisional hernia rate but at the cost of increased pain at 24 h, higher risk of GB perforation, port site bleeding and technical difficulties.

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An updated meta-analysis providing better evidence on gall bladder extraction port following laparoscopic cholecystectomy(LC).

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Epigastric port retrieval of gallbladder following LC has advantage of reduced rate of both infection and incisional hernia.

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Umbilical port retrieval of gallbladder following LC has advantage of reduced pain, port site bleeding and perforation risk.

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In conclusion from this meta-analysis epigastric port retrieval seems to be more advantageous compared to the umbilical port.