bluuebunny/crossref_metadata_2025 huggingface dataset:
P-OGC78 One year experience of a newly established super green ERAS pathway for performing oesophago-gastric cancer resections during the Covid-19 pandemic
Authors: Sahni Dhruv , Khan Khurram , Gall Lewis , Kosk Paulina , Forshaw Matthew , Macdonald Andrew , Craig Carol , MacKay Colin
Published: December 2021

Background

Surgical oncology services in the UK have been impacted by the COVID-19 pandemic.  Various strategies have been employed in an attempt to continue cancer resectional surgery   during the pandemic.  This study examined our institution’s experience and outcomes with a newly established Super Green ERAS pathway for oesophago-gastric (OG) cancer resections during the pandemic.

Methods

A retrospective cohort study of consecutive patients who had a resection for OG cancer performed over a 12-month period beginning from the date of the first UK National Lockdown of 23 March 2020.  Barring two intervals each lasting 3 weeks, urgent elective cancer surgery continued on our mixed hot and cold site through the establishment of a Super Green ERAS pathway.

Patients were confirmed COVID-19 negative within 72 hours pre-admission and retested  72-hourly post-op. 14 days self-isolation pre-admission was mandated.  Patients not complying had their surgery postponed. Transhiatal oesophagectomy was the preferred approach for oesophagectomy during the pandemic. 

Results

45 resections (33 oesophagectomies, 10 gastrectomies and 2 trial of dissections) were performed.  37 (82.2%) patients were male with a median age of 64 (IQR 58-71) years.   3 patients were postponed due to non-adherence with self-isolation.

No patients tested positive for COVID-19 post-operatively, hence, there was no COVID-19-related morbidity. Nine patients developed pneumonia. Seven patients had an anastomotic leak, all of whom were successfully rescued. One patient required a clamshell thoracotomy due to intra-operative mediastinal bleeding followed by a return to theatre for reconstruction 48hrs later.  Median length of stay was 12 (IQR 9-18) days. There was no in-hospital mortality.

Conclusions

OG cancer resections can be performed safely despite COVID-19, with favorable clinical outcomes when a Super Green ERAS pathway is strictly adhered to.   Implementation of such pathways will enable surgical oncology services, including OG cancer resections, to continue to ensure best possible outcomes for cancer patients despite any future waves of the COVID-19 pandemic.
P-OGC89 Peri-operative blood use in Upper GI surgery
Authors: Mercer Alexandra , Houston Martin , Harris Andrew , Millen Steven
Published: December 2021

Background

One group and hold sample costs approximately £18 to process whilst it costs £170 to prepare and administer 1 unit of cross matched blood. We aimed to quantify the amount of blood cross-matched for elective oesophagectomy and gastrectomy cases and compare this to the number of units transfused in the peri-operative setting (within 24 hours of surgery). Current unit guidance required all patients to be cross matched for 2 units of blood pre-operatively. 

Methods

Baseline data was collected retrospectively over a 10 week period (08/07/19-16/09/19). A new blood ordering protocol, made in agreement with oesophago-gastric and anaesthetic consultants was produced. Blood was only to be requested if: antibodies on group and hold, pre-op Hb < 120g/l, operative team concerns or previous radiotherapy. Data was recollected using the same parameters post -intervention over a 10 week period (23/12/19-08/03/20). 

Results

Before implementation of the protocol 24 patients were included, mean age 67 (range 40-84). All patients were cross matched between 2 and 4 units, with a total of 52 units requested and only 1 transfused. After implementation of the protocol 27 patients were included, mean age 69 (range 51-87). 36 units were ordered for 15 patients and 3 units were transfused. The new protocol was correctly implemented in 19 patients (70%). If implemented correctly in all patients in this group a saving of approximately £6120 could have been made. This could equate to a saving of as much as £20,400 per year based on 90 OG operative cases.

Conclusions

Patients were cross-matched far in excess of their transfusion needs. There was significant reduction in the number of patients being cross-matched post intervention. Rationalising this is important to reduce waste, reduce cost and cut down on delays to maximise theatre time.
P-OGC93 Weight Loss and Complications in Oesophagectomy and Gastrectomy Patients
Authors: Ramdin Ashling , Dawas Khaled
Published: December 2021

Background

Oesophagectomy and gastrectomy are major surgeries which often involve patients fasting for prolonged periods of time post operatively thus requiring alternative nutrition regimens. In addition, patients often suffer dysphagia, anorexia, chemotherapy side effects and significant weight loss prior to surgery. Post-operative concerns include delayed gastric emptying, refeeding syndrome and dumping syndrome. Whilst placement of enteral feeding tubes aids the transition back to normal diet there are often still social, physical and dietary challenges that hinder nutrition. The aim of this study was to review weight loss in patients post operatively and to optimise post-operative nutrition. 

Methods

The records of 113 patients who had undergone an oesophagectomy (43) or gastrectomy (64) between June 2018 and November 2019 at a single regional cancer centre were retrospectively examined. These patients’ contemporaneous weights had been recorded at set peri operative timelines and the greatest percentage weight loss calculated. The percentage weight loss was matched to the highest Clavien-Dindo post-operative complication. 

Results

89 patients had weights routinely reviewed post operatively, with the remainder not having regular post operative weights documented. The median weight loss was 7.53. 

For patients undergoing a total gastrectomy (27) weight loss ranged from 7.36-29.2%. Median weight loss was 11.45%. Patients who underwent subtotal gastrectomy (26) had between 0.37-18.5% with a median of 7.83% weight loss. Those who underwent an oesophagectomy (36) had between 0 - 28.67% weight loss with the median being 7.21%. 6 patients had their operations abandoned. 

Post-operative complications, inclusive of Grade II and above, occurred in 16.8% of cases. Majority of complications occurred in those undergoing an oesophagectomy (64%), however complications did not correlate with percentage weight loss. The most common complication was grade IIIb (Grade I: 8, Grade II: 1, Grade IIIa: 1, Grade IIIb: 14, Grade IVa: 2, Grade V: 2). 

Conclusions

Significant post-operative weight loss is common after oesophagectomy or gastrectomy surgery. Postoperative weight loss did not correlate with complications. Furthermore, there did not appear to be a correlation with weight loss and type of procedure. Nutritional status plays an important prognostic role in patients undergoing oesophagectomy or gastrectomy. Optimising nutrition perioperatively and post operatively is important to enhance post-operative recovery and reduce post operative risk. Reviewing a larger cohort of patients would improve the robustness of this study.
P-OGC95 Understanding the molecular age of Barrett’s oesophagus in a population-representative sample of patients
Authors: Oliveira Talita , Lewis McKenna , Smyth Laura , Turkington Richard , McKnight Amy Jayne , Cairnduff Victoria , McManus Damian , Johnston Brian , Coleman Helen , Curtius Kit
Published: December 2021

Background

The incidence of oesophageal adenocarcinoma (OAC) increases dramatically with patient age but only a small proportion of patients with diagnosed Barrett’s oesophagus (BO), the precursor to OAC, will develop dysplasia and/or cancer. Beyond chronological age, biomarkers of progression that capture biological aging offer largely untapped potential for objectively identifying BO patients at highest risk of progression, who could undergo personalised surveillance at shorter intervals. We have developed computational tools to determine tissue-specific aging using genome-wide methylation data as a “molecular clock” for estimating patient-specific BO dwell times at the time of incident diagnosis that cannot be clinically measured by other means. 

Methods

Using the population-based Northern Ireland BO register in a retrospective study, we have identified 46 non-dysplastic BO patients who have 2-4 serial endoscopic biopsies each, and have not progressed to OAC (age range 29-77 years).  FFPE biopsies for 10 age-matched patients who had prevalent HGD/OAC at index BO diagnosis were also retrieved. DNA has been extracted, quantified using fluorescence, quality checked through qPCR, and prepared for Illumina EPIC methylation arrays. We created a Python package called “MethylDrift” to determine genome-wide aging rates in patient data. Model outputs are used in the molecular clock for BO tissue age.

Results

We used MethylDrift to quantify aging rates in both cross-sectional data (population-level epigenetic drift) and longitudinal data within the same patients to obtain individual aging rates. Computational analyses using our previously developed Bayesian framework for the BO molecular clock will be applied to estimate the molecular age of BO in patients, i.e., how long the patient has been living with BO since onset of metaplasia. Results will be compared between age groups, birth cohorts, sex, and importantly between dysplastic and non-dysplastic BO to evaluate biomarker potential. Data analysis is ongoing, and the final results will be presented at the meeting.

Conclusions

Our results from this nested case-control study demonstrate feasibility and generate pilot data on molecular age as a proxy of BO duration at the time of incident diagnosis, in a large population-based registry of patients with BO. This will inform our computational tools for determining biological aging and can be applied in future work to investigate progression risk according to molecular age. Ultimately, this biomarker could inform surveillance frequency for BO patients, enable earlier detection of neoplastic progression, leading to improved patient outcomes and optimal distribution of limited endoscopy capacity for surveillance.
P-P05 Acute Pancreatitis during COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in Western Health and Social Care Trust
Authors: Yawar Bakhat , Marzouk Ahmed , Ali Heba , Bahli Zahid , Abousamra Mohammad , Asim Ayeisha
Published: December 2021

Background

Acute pancreatitis is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. COVID-19 pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, primary aim was to ascertain incidence of COVID-19 in acute pancreatitis patients. Secondary objectives were to study aetiology, demographics, severity, 30 day mortality, outcomes and management of acute pancreatitis patients from Altnagelvin Area Hospital from 1st March, 2020 till 30th August, 2020.

Methods

A retrospective observational review of all patients admitted under General Surgical team from March 2020 till September 2020 was performed. Information regarding demographics, severity of acute pancreatitis (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected based on RedCap tool used by COVID-PAN study. The results were compared to outcomes results of COVID-PAN study for COVID-19 negative patients in that study as we had only one patient who was positive for COVID-19 at time of concomitant pancreatitis diagnosis.

Results

Forty four (44) patients were admitted with acute pancreatitis. Only one patient (2.3%) was diagnosed with COVID-19 at time of pancreatitis. Aetiology of pancreatitis was found comparable to aetiology reported by large scale studies (2). Mortality was 7% (3 patients). Five patients (11%) needed ICU admission due to organ dysfunction. Three patients (7%) developed ARDS. 

Conclusions

The overall incidence of COVID-19 in pancreatitis in our population of study was low. Therefore, results were compared to patients who were COVID-19 negative in COVID-PAN study. Patients with acute pancreatitis in our target population were mostly elderly, about one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As has been observed in other centres globally, urgent for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4 out of 19 patients having undergone interval cholecystectomy.
P-P11 A tumour responsive, oxygen-generating nanoparticle to combat hypoxia in pancreatic tumours
Authors: Farrell Sian , Nicholas Dean , Nesbitt Heather , Logan Keiran , McMullin Eva , Gillan Tierna , Kelly Paul , O'Rourke Declan , Porter Simon , Thomas Keith , O'Hagan Barry M.G. , Nomikou Nikolitsa , Callan Bridgeen , Callan John F. , McHale Anthony P.
Published: December 2021

Background

Pancreatic cancer remains a significant therapeutic challenge and its poor prognosis has remained relatively unchanged for the past 40 years.    Pancreatic tumours are highly desmoplastic and impenetrable lesions in which both gas and mass transfer is severely compromised.   This leads to the development of hypoxia within the tumour and this compromises therapeutic approaches that rely on cytotoxic reactive oxygen species, e.g. photodynamic therapy, sonodynamic therapy and radiotherapy.     Hypoxia also results in a relatively low pH within the tumour microenvironment.  Here we describe a pH sensitive nanoparticle that can generate oxygen in the tumour and enhance ROS generating therapeutic approaches.

Methods

CaO2 NPs were generated by exposing to low frequency ultrasound and subsequently coated using a polymethacrylate polymer that becomes soluble at pH 6.4.   For some studies, the sonosensitiser, Rose Bengal was attached to the particles.   Oxygen generation in tumours (BxPC3) was demonstrated by inserting a dissolved oxygen probe into tumours following IV administration of particles.  Particles were also employed together with photodynamic therapy (PDT) and sonodynamic therapy (SDT) using human xenograft and syngeneic pancreatic tumour models.  In some cases, tumour tissues were recovered and analysed for tumour infiltrating immune cells using flow cytometry.

Results

Conclusions

Coating CaO2 nanoparticles with a pH sensitive polymer provides in situ oxygen generation in tumours. Transient provision of oxygen enhances therapies that depend on the generation of cytotoxic reactive oxygen species. When used with SDT, and using a bilateral syngeneic pancreatic tumour model, a powerful abscopal effect was observed and this was shown to be immune-mediated. The above data suggest that the particles may be exploited to enhance other therapies that depend on the generation of ROS, e.g. radiotherapy, and further suggest that the approach can be used to treat either local or disseminated forms of pancreatic cancer.
P-P22 NET Profit: Considering quality of life assessment in patients treated with SSAs for NETs
Authors: Hall Lewis , Powell-Brett Sarah , Thompson Oscar , Bradley Elizabeth , Smith Stacey , Vickrage Suzanne , Kemp-Blake Joanne , Shah Tahir , Roberts Keith
Published: December 2021

Background

Somatostatin Analogue (SSA) therapy of neuroendocrine tumours (NETs) leads to pancreatic exocrine insufficiency (PEI). PEI symptoms include diarrhoea, abdominal discomfort, bloating, and steatorrhea, which negatively impact quality of life (QoL). NETs (and the sequelae of carcinoid syndrome) however, have similar symptomatology to PEI, with a comparably negative impact on QoL. QoL tools exist to assess PEI and its response to enzyme therapy; however, we hypothesise that PEI symptom scale scores will be unreliable in SSA-induced PEI due to the concurrent improvement of the carcinoid symptoms.

Methods

Adult patients commencing SSA therapy for NETs were recruited from December 2020. Qualitative assessments of the impact of SSAs and pancreatic exocrine function on patient QoL were performed before and during (at 8 weeks) therapy. The Pancreatic Exocrine Insufficiency Questionnaire (PEI-Q) was used to capture patient-reported assessment of relevant symptoms. Health-related QoL was assessed using the  European Organisation Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLC)-C30, supplemented by the EORTC GI.NET.21. Patients were specifically asked about steatorrhea at both assessments.

Results

Seven patients completed the study. 5-HIAA levels were raised in 4/7 patients, indicative of carcinoid syndrome, secondary to the NET. Pancreatic exocrine function reduced after SSA therapy in all patients (data reported elsewhere) but paradoxically PEI-Q symptom scale scores reduced (median decrease from baseline: -18.5%, range: -1.5- -55.6%; p = 0.018) (Figure 1). According to PEI-Q, all seven patients would meet the criteria for a mild PEI at baseline, and two would be considered severe. One patient reported steatorrhea after commencing SSA-therapy. No changes in relevant domains of EORTC questionnaires were statistically significant, including functional, symptomatic, and overall health scores.

Conclusions

The PEI-Q tool is not useful for assessing SSA-related PEI due to substantial symptom overlap with the tumour itself and SSA therapy. The decrease in symptom score is likely due to improvement of carcinoid syndrome, independent of PEI. Although the cardinal PEI symptom is steatorrhea, there is no distinction between that and diarrhoea in the EORTC tool, and confounding aetiologies of diarrhoea in NET patients may further complicate assessment. Current available QoL measures are of limited use in the setting of SSA-related PEI, and care should be taken if evaluating PEI or response of PEI to treatment.
P-P23 Adjuvant chemotherapy in the treatment of intraductal papillary mucinous neoplasms of the pancreas: systematic review and meta-analysis
Authors: Chong Eric Jing Fu , Ratnayake Bathiya , Dasari Bobby V M , Loveday Benjamin PT , Siriwardena Ajith K , Pandanaboyana Sanjay
Published: December 2021

Background

The present systematic review aimed to compare survival outcomes of invasive intraductal papillary mucinous neoplasms (IIPMNs) treated with adjuvant chemotherapy versus surgery alone and to identify pathologic features that may predict survival benefit from adjuvant chemotherapy.

Methods

A systematic search of Medline, Pubmed, Scopus, and EMBASE was performed using the PRISMA framework. Studies comparing adjuvant chemotherapy and surgery alone for patients with IIPMNs were included. Primary endpoint was overall survival (OS). A narrative synthesis was performed to identify pathologic features that predicted survival benefits from adjuvant chemotherapy.  

Results

Eleven studies and 3393 patients with IIPMNs were included in the meta-analysis. Adjuvant chemotherapy significantly reduced risk of death in the overall cohort (HR 0.57, 95%-CI:0.38-0.87, p = 0.009) and node-positive patients (HR 0.29, 95%-CI:0.13-0.64, p = 0.002). Weighted median survival difference between adjuvant chemotherapy and surgery alone in node-positive patients was 11.6 months (95%-CI:3.83-19.38, p = 0.003) favouring chemotherapy. Adjuvant chemotherapy had no impact on OS in node-negative patients (HR 0.53, 95%-CI:0.20-1.43, p = 0.209). High heterogeneity (I2>75%) was observed in pooled estimates of hazard ratios. Improved OS following adjuvant chemotherapy were reported for patients with stage III/IV disease, tumour size >2 cm, node-positive status, grade 3 tumour differentiation, positive margin status, tubular carcinoma subtype, and presence of perineural or lymphovascular invasion.

Conclusions

Adjuvant chemotherapy was associated with improved OS in node-positive IIPMNs. However, the findings were limited by marked heterogeneity. Future large multicentre prospective studies are needed to confirm these findings and explore additional predictors of improved OS to guide patient selection for adjuvant chemotherapy.
P-P36 AXIOS™ stents in the management of pancreatic fluid collections: case series from a single healthcare trust
Authors: Doyle Joseph , Latip Nadiah , McCain Stephen , Scott Ryan , Love Mark , Taylor Mark , Vass David , Jones Claire , Kirk Gareth , McKie Lloyd , Diamond Thomas
Published: December 2021

Background

This was a consecutive case-series of all pancreatic fluid collections (PFCs) managed with AXIOS™ stents in a 3 year period from a single healthcare trust, retrospectively analysed to determine the rate of technical success, clinical success and adverse events related to the procedure.

Methods

All patients in who underwent AXIOS stenting for PFCs in the Belfast Health and Social Care Trust between May 2016 and July 2019  were included, with a follow-up period of 1 year. Electronic care records (ECR) and Radiology reports were reviewed for each patient. PFCs were categorised into walled-of pancreatic necrosis (WOPN) and pseudocysts as per the revised Atlanta classification. The number of repeat procedures, endoscopic lavage +/- necrosectomy, the need for definitive surgery or any adverse events post-procedure were recorded.

Results

45 patients were included in the study (21 male, 24 female). 17 patients (37.8 %) had WOPN and 28 (62.2 %) pancreatic pseudocysts. Median collection diameter on CT imaging was 12 cm (range 6.2 – 22 cm).

The procedure was technically successful in 43 patients (95.6%), with stent mal-deployment in the remaining 2. Median duration for stenting was 29.5 days (Range 13 – 92).

The procedure was clinically successful for 33 patients (73.3%). n = 8 (17.8%) of patients were re-admitted with sepsis following stent insertion requiring intravenous antibiotics. n = 16 (35.6%) patients required repeated endoscopic lavage +/- necrosectomy following stent blockage (n = 11 WOPN, n = 5 pseudocyst). n = 2 (4.4%) stents accidentally dislodged during lavage necessitating surgical removal. n = 4 (8.9%) patients required a second AXIOS stent within 45 days of removal, n = 2 (4.4%) required CT guided drainage and n = 8 (17.8%) ultimately required surgical intervention.The rate of adverse events post-procedure was 33.3%.

Conclusions

AXIOS stenting appears to be effective first-line in the “step-up” approach to managing PFCs. Despite some drawbacks, our study showed they were technically successful in 95.6% and clinically successful in 73.3% of cases, requiring no further intervention. For PFCs that do require surgery, AXIOS stenting may allow for a period of patient optimisation prior to definitive treatment.
P-P38 External validation of post-operative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis
Authors: Pande Rupaly , Halle-Smith James , Phelan Liam , Thorne Tom , Hodson James , Roberts Keith J ,   PARANOIA Study Group
Published: December 2021

Background

Multiple risk scores claim to predict the probability of post-operative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation which score is the most accurate. 

Objective: To identify risk scores and assess the clinical validity of these scores. 

Methods

Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models. 

Results

Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so were included in the meta-analysis, namely the Tokyo (N = 2 validation studies), Birmingham (N = 5), FRS (N = 19), a-FRS (N = 12), m-FRS (N = 3) and ua-FRS (N = 3) scores.  The overall predictive accuracies were found to be similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%.

Conclusions

Most risk scores lack external validation, their predictive accuracies were limited and similar across risk scores. Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.
P-P39 Perioperative Interventions to Reduce Pancreatic Fistula following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis
Authors: Halle-Smith James , Pande Rupaly , Hall Lewis , Hodson James , Roberts Keith J ,   PARANOIA Study Group
Published: December 2021

Background

Many studies evaluate interventions to reduce POPF following PD, but often report conflicting results. Previous meta-analyses have generally included non-randomised trials and not considered novel interventions. 

Aim

To evaluate interventions to reduce postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) with level 1 data.

Methods

A systematic review and meta-analysis assessed randomised controlled trials (RCTs) evaluating interventions to reduce All-POPF or clinically relevant (CR)-POPF after PD. A post-hoc analysis of negative RCTs assessed whether these had appropriate levels of statistical power.

Results

Among 22 interventions (n = 7,512 patients, 55 studies), 12 were assessed by multiple studies, and subject to meta-analysis. Of these, external pancreatic duct drainage was the only intervention found to be associated with significantly reduced rates of CR- and all-POPF. In addition, Ulinastatin was associated with significantly reduced rates of CR-POPF, whilst invagination (vs duct to mucosa) pancreatojejunostomy was associated with significantly reduced rates of all-POPF. Review of negative RCTs found the majority to be underpowered, with post-hoc power calculations indicating that interventions would need to reduce the POPF rate to ≤ 1% in order to achieve 80% power in 16/34 (All-POPF) and 19/25 (CR-POPF) studies, respectively.  

Conclusions

Meta-analysis supports a role for several interventions to reduce POPF after PD, although data is often inconsistent and/or based on small trials. Systematic review identifies other interventions which may benefit from further study. However, underpowered trials appear to be a fundamental problem, inherently more so with CR-POPF. Larger trials, or new directions for research are required to further understanding in this field.
P-P40 Can trainees safely perform pancreatoduodenectomy? A systematic review, meta-analysis and risk-adjusted analysis of post-operative pancreatic fistula
Authors: Pande Rupaly , Halle-Smith James , Thorne Tom , Hodson James , Roberts Keith J ,   PARANOIA Study Group
Published: December 2021

Background

The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining operative experience. 

Objective

to compare the POPF rate following PD by trainees or established surgeons.

Methods

A systematic review of the literature was performed using PRISMA guidelines, with differences in POPF rates after PD between trainee-led vs. consultant/attending surgeons pooled using meta-analysis. Variation in rates of POPF was further explored using risk-adjusted outcomes using published risk scores and CUSUM analysis in a retrospective cohort.   

Results

Across 14 cohorts included in the meta-analysis, trainees tended towards a lower, but non significant rate of All-POPF (odds ratio [OR]: 0.77, p = 0.45) and clinically relevant (CR)-POPF (OR: 0.69, p = 0.37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3mm (OR: 0.45, p = 0.05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted All-POPF (median: 20 vs. 26%, p < 0.001) and CR-POPF (7 vs. 9%, p = 0.020) rates than consultant/attending surgeons, based on pre-operative risk scores. After adjusting for this on multivariable analysis, the risks of All-POPF (OR: 1.18, p = 0.604) and CR-POPF (OR: 0.85, p = 0.693) remained similar after PD by trainee or consultant/attending surgeons.

Conclusions

PD, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.
P-P41 Systematic review of Sarcopenia in Chronic Pancreatitis: prevalence, impact on surgical outcomes and survival
Authors: Bundred James , Thhakar Rohan G , Pandanaboyana Sanjay
Published: December 2021

Background

Chronic pancreatitis(CP) is characterised by progressive inflammatory changes to the pancreas, leading to loss of endocrine and exocrine function. Emerging literature suggests sarcopenia may adversely affect outcomes for chronic pancreatitis patients. This systematic review examines the evidence surrounding the impact of sarcopenia on patients with CP.

Methods

A systematic literature search of PUBMED, MEDLINE and EMBASE databases identified articles describing body composition assessment in patients with CP. Data collected included definitions of sarcopenia, assessment methodology, baseline demographics, surgery related data and short- and long-term outcomes.

Results

9 studies, including 977 patients and a sarcopenia prevalence of 32.3% were included. Alcohol was the predominant aetiology. There was significant heterogeneity in definitions of sarcopenia used. CT was the main modality to assess for sarcopenia in 7 papers, MRI in 2 papers and clinical measurements in 2 papers. 2 papers included patients undergoing total pancreatectomy and Islet cell transplantation. None of the studies found a significant increase in complications with sarcopenia. 1 Year mortality in outpatients from one study of patients with CP was 16% in sarcopenic patients versus 3% (HR:6.69(95%CI:1.79–24.9),p<0.001).

Conclusions

Sarcopenia is prevalent in patients with CP and has adverse impact on short- and long-term survival.
P-P45 Prognostic Value of CRP in Post-PPPD and Whipple’s Re-Intervention
Authors: Macias Ana Maria Saenz , Frampton Adam
Published: December 2021

Background

Several studies have aimed to use different biochemical and haematological markers to predict relevant post-operatively pancreatic fistulas after hepatobiliary operations, however none has been defined as the gold-standard. This study aimed to evaluate the sensitivity and specificity of day 3 C-reactive protein (CRP) and drain amylase values in predicting re-intervention in patients who have undergone pancreatico-duodenectomy (PPPD) or Whipple’s procedure.

Methods

Retrospective collection of data from a prospective database of patients who underwent PPPD or Whipple’s procedure between January 2017 and February 2021.

Serum CRP was collected from day one to day five post-operatively, and day three or the closest available result of post-surgery drain amylase values were considered. Cutoff values were determined as follows: day three CRP optimal level was determined by the median (175 mg/L), and drain amylase was determined by three times the upper limit of normal serum amylase level (330 U/L).

Post-operative pancreatic fistulas (POPF) were classified as per the 2016 International Study Group for Pancreatic Surgery (ISGPS). Re-intervention was defined as any deviation from the normal post-surgical care – including interventional radiology procedures, embolisation, re-look laparotomies and re-admission to Intensive Care.

Results

A total of 217 patients were included in this study – 182 underwent pylorus preserving pancreaticoduodenectomy as opposed to those who had Whipple procedure. 55 (25%) patients required re-intervention post-operatively. A day three CRP above 175 showed a sensitivity of 78% and specificity of 66% in predicting re-intervention in these patients. The combination of this and elevated drain amylase proved to be more sensitive (85%) and specific (87%) than the CRP alone.

Conclusions

Day 3 CRP and drain amylase are accurate predictors of post-PPPD and Whipple’s re-interventions. We aim to include this as part of the local Enhanced Recovery Pathway to help identify patients that will potentially develop complications requiring further surgical management.
P-P46 The use of FDG-PET/CT in the pre-operative staging of pancreatic ductal adenocarcinoma
Authors: Jordan Rebecca , Muir Duncan , van Laarhoven Stijn , Falk Stephen , Strickland Andrew , Skipworth James
Published: December 2021

Background

 The NICE Quality Standard for Pancreatic Cancer (December 2018) recommends that ‘adults with localised pancreatic cancer on CT(should) have staging using fluorodeoxyglucose positron emission tomography/CT(FDG-PET/CT) before they have surgery, radiotherapy or systemic therapy’. Such FDG-PET/CT staging aims to provide additional information to conventional cross-sectional imaging, thus presenting the most accurate staging of disease. However, the sensitivity and specificity of FDG-PET/CT to deliver relevant additional clinical information must be balanced with potential delays to treatment, and additional cost associated with its use, in the management of a time-critical pathology.

Methods

Consecutive pancreatic ductal adenocarcinoma(PDAC) patients deemed resectable on conventional imaging, and therefore referred for FDG-PET/CT assessment, were included for analysis. Data were derived from a single tertiary Hepatopancreaticobiliary(HPB) centre between May 2018 and June 2021. Data were collected and analysed from a combination of prospectively-collated electronic databases and paper patient records.

Results

Of 89 patients analysed, 55(61.7%) patients were male. Primary pancreatic lesions were PET avid in 81 cases(91%). Median time from request to FDG-PET/CT performance was 11 days(Range 1-35).

Additional clinical information from FDG-PET/CT was provided in 61(68.5%) patients. Further investigations to assess FDG-PET/CT findings were arranged in 23 patients(25.8%; including liver MRI and EUS), demonstrating that FDG-PET/CT findings were true-positive in 6(26.1%), false-positive in 15(65.2%) and equivocal in 2(8.7%). There was a median delay of 60.5 days(Range 26 to 256) from FDG-PET/CT to surgery in those undergoing additional investigation. In total, a new diagnosis of metastatic/non-resectable disease was made in 14(15.7%) patients, preventing progression to planned operative intervention.

Conclusions

FDG-PET/CT provided additional information to conventional imaging that led to cancellation of planned operative resection in 14(15.7%) PDAC patients-8 directly and 6 following further investigation. However, there was a median delay of 11 days to FDG-PET/CT and 60.5 days from FDG-PET/CT to surgery in those undergoing additional investigation.  

Whilst FDG-PET/CT can lead to avoidance of unnecessary surgical intervention in PDAC patients with unsuspected metastatic/non-resectable disease, it can lead to delay, over-investigation, excess cost and anxiety in resectable patients. HPB units should audit their own findings to assess whether the use of FDG-PET/CT should be considered on a standard or selected basis.
P-P51 Assessing the severity of pre and post-operative malnutrition in cancer patients undergoing pancreaticoduodenectomy: A review of a virtual dietetic prehabilitation service
Authors: Cox Leah
Published: December 2021

Background

The prevalence of malnutrition amongst pancreatic cancer patients is widely reported. This is due to reduced nutritional intake, increased energy expenditure and increased nutrient losses secondary to malabsorption. A Whipple's procedure or pancreaticoduodenectomy is the only potentially curable intervention for pancreatic cancer patients. Malnutrition is associated with increased peri and post-operative complications including delayed wound healing, longer hospital admission and higher mortality rate. Dietetic prehabilitation is a proactive intervention to assess patients’ nutritional status in preparation for elective surgery and, through early dietetic intervention, has the potential to improve perioperative outcomes. This pilot study reviewed the severity of nutritional risk in both the pre and post-operative stages to understand the need for dietetic prehabilitation in this patient group.

Methods

All patients referred were nutritionally assessed as part of a dietetic cancer prehabilitation pathway, which includes pre-surgical nutritional assessment within one week of referral and early post discharge nutritional assessment. Nutritional assessment was carried out using the PG-SGA short form and patients were triaged as requiring either a universal, targeted or specialist dietetic intervention dependent on severity of nutritional risk. Patients who scored <4 were triaged as universal, and were low nutritional risk. Patients who scored 5-9 were triaged as targeted and were medium nutritional risk, and patients who scored >9 were triaged as specialist, and were high nutritional risk.

Results

35 patients were referred for dietetic prehabilitation assessment. 71% of patients were triaged as requiring either a targeted or specialist prehabilitiation intervention. BMI ranged from 15.7kg/m² to 35.9kg/m² and median weight loss was 10.0%. 23 patients received early post surgical nutritional assessment, within 12 days of discharge from hospital. All 23 patients required targeted or specialist dietetic intervention. 22 patients reported post-operative weight loss, with a median weight loss of 7.5%. There was no correlation between pre-surgical and post-surgical nutritional risk.

Conclusions

Patients undergoing pancreaticoduodenectomy are at high nutritional risk in both the pre and post-operative periods. Patients without evidence of malnutrition in the pre-operative stage remain at high risk of malnutrition and the associated complications in the post operative stage. A prehabilitation programme can identify patients at nutritional risk and institute interventions to optimise perioperative nutritional status.  Findings from this review will form the basis of a study examining the effects of a prehabilitation programme on outcomes following pancreaticoduodenectomy.
P-P53 Textbook outcomes in pancreatoduodenectomy are improved in high volume specialist pancreas-only centres
Authors: Vedamanickam Pon Rachel , McKay Siobhan C , Raza Soulat , Laing Richard , Bhatt Anand , Durkin Damien , Athwal Tejinderjit
Published: December 2021

Background

Traditional single surgical quality indicators are commonly used however they are poor for assessing global outcomes for patients. Composite outcomes such as the ‘Textbook Outcome’ (TO) is a composite outcome to determine the success of the quality of the surgical process, and compare outcomes between institutions and patient groups, described by the Dutch Pancreatic Cancer Audit Group for Pancreatoduodenectomy (PD).  They reported national TOs for PD of 58.3%, we compared this to TOs in a UK high volume specialist pancreas-only centre, Royal Stoke. 

Methods

Patients who underwent PD from January 2017 to December 2020 were identified from our database. TO was defined as absence the following: post-operative pancreatic fistula (POPF) (grade B/C), post-pancreatectomy haemorrhage (PPH), bile leak, severe complications (Clavien Dindo grade III or more), 30-day readmission and 30-day mortality. 

Results

153 patients underwent PD during the 4-year study period. The median age was 71years (range 37-85 years), and there was a slight male preponderance (54.9%, 84/153).  47% had pancreatic ductal adenocarcinoma (72/153), 17% ampullary carcinoma (26/153), 9% cholangiocarcinoma (14/153), 9% duodenal carcinoma (14/153), and benign pathology included cases with IPMN and duodenal polyps with high grade dysplasia. There was a statistically significant difference in textbook outcome in our cohort compared to the Dutch Study (70.3%, 108/153 vs 58.3%, 895/1536; p=0.003086), with components of TO shown in Figure 1.

Conclusions

TO represent composite outcome for identifying good practice, areas for shared learning and areas for improvement. PD performed in high-volume pancreas-only specialist centers appear to have better outcomes following PD than lower-volume centres.  Further investigation is required to assess why outcomes are different between centres, and identify how best practice can be shared.
P-P55 CT-PET use in potentially resectable pancreatic cancer
Authors: Thorne Thomas , McKay Siobhan C , Hall Lewis , Wilkin Richard , Pathak Samir , Barrie Jenifer , Moir John , Roberts Keith J ,   on behalf of the Surg-Panc-UK Study Group
Published: December 2021

Background

CT-PET has become increasingly used in the diagnostic pathway for pancreatic cancer (PC)and was introduced into National Guidelines (NICE) in 2018 in the United Kingdom. It can improve the diagnosis of metastatic disease, though some believe it is not significantly better than a staging CT and MRI, and there are concerns that it can significantly delay the treatment pathway for patients, without adding benefit.

Methods

A retrospective national study undertaken by 26/27 specialist pancreatic resectional centres in the United Kingdom. All adult patients listed for pancreatoduodenectomy for suspected PC were included. Baseline demographics, length of pathway (days from MDT to surgery), number and type of investigations, interventions (ERCP or PTC) and associated complications were recorded, in addition to the operation performed and 12-month survival. Patients undergoing neoadjuvant chemotherapy were excluded.

Results

1709 cases were entered from 2017-2020. 155 patients were excluded due to neoadjuvant chemotherapy, with 8 further patients excluded due to incomplete data entry. The median age was comparable for patients undergoing CT-PET (68 years IQR 60.0-73.0) and those who did not undergo CT PET (68 years IQR 60.0-74.0). 363/1546 patients (23.5%) underwent a pre-operative CT-PET. There was a significantly longer pathway with CT-PET (56 vs 42 days, p < 0.001) and a non-significant tendency towards an increased bypass rate with CT-PET (9.9% vs. 7.8%, p = 0.065), and no improvement in survival (1-year survival 76.9% vs 75.7%, p = 0.712).

Conclusions

There is a statistically significant increase in the length of pathway with CT-PET, without any improvement in bypass rate or one year survival compared the no-CT-PET group.  CT-PET undoubtedly has benefits but should be used selectively rather as standard investigation for all patients as failed to demonstrate survival improvement.
Visiting Plants of Mamestra brassicae (Lepidoptera: Noctuidae) Inferred From Identification of Adhering Pollen Grains
Authors: Guo Jianglong , Liu Yongqiang , Jia Huiru , Chang Hong , Wu Kongming
Published: December 2021

Numerous lepidopteran adults frequently pick up plant pollen when feeding. Identifying plant species visited by Mamestra brassicae moths could further strengthen our knowledge of their migratory trajectory and the interactions of M. brassicae moths with these plant species. Here, with morphological analysis and DNA metabarcoding of pollen carried by the moths, we determined these plant species visited by M. brassicae during 2015–2018. Pollen grains removed from M. brassicae moths were identified from 25 species (18 were identified to genus), representing at least 19 families, including Pinaceae, Oleaceae, Rosaceae, and Asteraceae, but mainly belonging to Angiospermae, Dicotyledoneae. There were noticeable interannual differences (maximum value: 35.31% in 2018) and seasonal differences (maximum value: 33.28% in April–(including May)–June) in the frequency of M. brassicae moths with adhering pollen, but no noticeable difference based on sex. Meanwhile, we also found pollen from some species such as Citrus sinensis (Rutales: Rutaceae) and Melia azedarach (Rutales: Meliaceae) that grow in southern China, indicating that M. brassicae moths might migrate northward in spring. Our results demonstrate that the M. brassicae moth visits a variety of plant species during migration, and these findings promote our understanding of the interaction between moths and these plant species.
Biomechanical engineering analysis of an acute papillary muscle rupture disease model using an innovative 3D-printed left heart simulator
Authors: Marin-Cuartas Mateo , Zhu Yuanjia , Imbrie-Moore Annabel M , Park Matthew H , Wilkerson Robert J , Leipzig Matthew , Pandya Pearly K , Paulsen Michael J , Borger Michael A , Woo Y Joseph
Published: December 2021

OBJECTIVES

The severity of acute papillary muscle (PM) rupture varies according to the extent and site of the rupture. However, the haemodynamic effects of different rupture variations are still poorly understood. Using a novel ex vivo model, we sought to study acute PM rupture to improve clinical management.

METHODS

Using porcine mitral valves (n = 32) mounted within an ex vivo left heart simulator, PM rupture was simulated. The mitral valve was divided into quadrants for analysis according to the PM heads. Acute PM rupture was simulated by incrementally cutting from 1/3 to the total number of chordae arising from 1 PM head of interest. Haemodynamic parameters were measured.

RESULTS

Rupture >2/3 of the chordae from 1 given PM head or regurgitation fraction >60% led to markedly deteriorated haemodynamics. Rupture at the anterolateral PM had a stronger negative effect on haemodynamics than rupture at the posteromedial PM. Rupture occurring at the anterior head of the anterolateral PM led to more marked haemodynamic instability than rupture occurring at the other PM heads.

CONCLUSIONS

The haemodynamic effects of acute PM rupture vary considerably according to the site and extent of the rupture. Rupture of ≤2/3 of chordae from 1 PM head or rupture at the posteromedial PM lead to less marked haemodynamics effects, suggesting a higher likelihood of tolerating surgery. Rupture at the anterolateral PM, specifically the anterior head, rupture of >2/3 of chordae from 1 PM head or regurgitation fraction >60% led to marked haemodynamic instability, suggesting the potential benefit from bridging strategies prior to surgery.