bluuebunny/crossref_metadata_2025 huggingface dataset:
P-OGC56 Do patients presenting with obstructing oesophageal cancer have worse outcome?
Authors: Chien Siobhan , Khan Khurram , Gall Lewis , MacKay Colin , Macdonald Andrew , Craig Carol , Forshaw Matthew
Published: December 2021

Background

Oesophageal cancer carries a poor prognosis.  Despite the availability of urgent Upper GI endoscopy in the United Kingdom, a substantial proportion of patients with newly diagnosed oesophageal cancer present late with near total dysphagia and an obstructing tumour at the index endoscopy.  There is little data analysing the effect of obstructing oesophageal cancer at presentation on overall prognosis.  The aim of the study was to analyse if patients presenting with obstructing oesophageal cancer have a worse outcome.

Methods

A retrospective cohort study of all newly diagnosed oesophageal cancers (adenocarcinoma and squamous cell carcinoma) and high grade dysplasia registered in a single UK Regional Upper GI MDT between October 2019 and September 2020 was performed.  Electronic records were interrogated and patients dichotomised into two groups based on if they were obstructed endoscopically or not on the index endoscopy and the results were compared.  Median follow up was 7 months.

Results

243 patients (68 (28.0%) obstructed and 175 (72.0%) non-obstructed) with median age of 70 were identified.  There were more females in the obstructed group (44.1% vs 25.7%, p = 0.005).  ECOG performance status was worse in the obstructed group: ECOG-0 (30.9% vs 50.3%, p = 0.006).   Adenocarcinoma was more common in non-obstructed group (69.1% vs 54.4%, p = 0.031).  More patients in the obstructed group had a T4 tumour (38.2% vs 18.9%, p = 0.002), however, nodal and metastatic status were similar.  Rates of curative intent treatment were similar.  At median follow-up of 7 months (IQR 3-13), more patients in obstructed group were deceased (72.1% vs 49.7%, p = 0.002).

Conclusions

Obstructing oesophageal cancer at presentation is a marker of advanced disease and despite curative treatment intent, overall survival is worse compared to passable tumours. New screening techniques such as Cytosponge combined with public health interventions to encourage early presentation may enable earlier diagnosis and improved survival.
P-OGC68 Prophylactic Endoluminal Vacuum Therapy (EVT) following oesophagectomy
Authors: Afzal Zeeshan , Gourgiotis Stavros , Hardwick Richard , Safranek Peter , Sujendran Vijayendran , Bennett John , O'Neill Robert , Noorani Ayesha , Hindmarsh Andrew
Published: December 2021

Background

Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for the management of anastomotic leaks following oesophagectomy. However, patients are often critically unwell with mediastinitis and established sepsis by the time the leak is diagnosed. This results in a protracted recovery period regardless of the effectiveness of EVT in treating the leak. Prophylactic EVT to protect the anastomosis following oesophagectomy may reduce the incidence of anastomotic leak, and/or mediastinitis and sepsis if the anastomosis does fail. We report the outcomes of two patients considered high risk for anastomotic leak who were managed with prophylactic EVT following esophagectomy for cancer.

Methods

Two patients received prophylactic EVT following oesophagectomy between May and July 2021. The patients were considered high risk for anastomotic leak due to technical concerns with, or complications during, the operation. In both cases the oesophagogastric anastomosis (OGA) was fashioned with a circular stapler. The endoluminal vacuum device (EVD) was constructed using an 18F nasogastric tube and a piece of open cell foam, and placed intraluminally across the anastomosis under endoscopic guidance at the time of surgery. Continuous negative pressure (125mmHg) was applied. Information relating to treatment and outcome was recorded prospectively.

Results

Patient-1, a 72-year-old female, ASA 2, underwent minimally invasive oesophgectomy for an adenocarcinoma at the gastro-oesophageal junction. After creating the stapled OGA, inspection revealed the proximal (oesophageal) tissue doughnut was complete but attenuated. Patient 2, a 67-year-old male, ASA 3, underwent a hybrid Ivor Lewis oesophgectomy for a lower 1/3 oesophageal adenocarcinoma. Surgery was complicated by significant intra-abdominal bleeding requiring blood transfusion and pressor support. In both cases, endoscopic assessment of the anastomosis following removal of the prophylactic EVD was performed day seven post-operatively. The anastomoses were healthy with no evidence of a leak, dehiscence, or early stricture formation.

Conclusions

In this limited case series, prophylactic EVT of the OGA following oesophagectomy was delivered safely with no complications related to insertion of the EVD or delivery of EVT. This intervention should be considered in cases where the risk of anastomotic leak is high. An intraluminal EVD situated across the OGA may minimise the extent of extraluminal contamination, and the systemic consequences of sepsis associated with this, should an anastomotic breakdown occur. Further studies are required to determine the safety of prophylactic EVT following oesophagectomy, and whether this improves surgical outcomes by reducing the incidence and impact of anastomotic leaks.
P-OGC73 Effect of pyloroplasty on the need for endoscopic intervention for delayed gastric emptying post oesophagectomy
Authors: Chien Siobhan , Khan Khurram , Gall Lewis , Craig Carol , MacKay Colin , Macdonald Andrew , Forshaw Matthew
Published: December 2021

Background

Delayed gastric emptying (DGE) is a common complication following oesophagectomy, affecting 15-39% of patients. Controversy remains regarding the role of pyloric drainage procedures during oesophagectomy with gastric conduit reconstruction in reducing DGE. This study investigated the effect of pyloroplasty at the time of oesophagectomy on the need for endoscopic pyloric intervention post-operatively.

Methods

We performed a retrospective analysis of all oesophagectomies performed in a single tertiary centre over a 10-year study period between 1 January 2010 and 31 December 2019. Electronic records were reviewed to analyse patient demographics, operative details and post-operative outcomes, as well as the need for endoscopic procedures after surgery. Patients were dichotomized into two groups, with those who had pyloroplasty performed at oesophagectomy compared to those who did not. Patients who died ≤30 days after oesophagectomy were excluded from analysis. Patients were followed up for a median of 32 months (IQR 19-60). 

Results

298 patients were eligible for the study, of whom 80/298 (26.8%) had a pyloroplasty performed. Demographics were evenly matched between the two groups. Patients undergoing Ivor-Lewis oesophagectomy were significantly more likely to have had pyloroplasty performed (90.0% vs. 24.3%; p < 0.001). Pyloroplasty had no significant effect on post-operative complication rates, ICU admission, need for re-operation or length of hospital stay. Patients without a pyloroplasty were significantly more likely to require endoscopic pyloric balloon dilatation (43.1% vs. 12.4%, p < 0.001) or pyloric botox injection (12.4% vs. 3.8%, p = 0.029) after oesophagectomy.

Conclusions

In this study, patients who had a pyloroplasty at the time of oesophagectomy were significantly less likely to require endoscopic pyloric balloon dilatation and/or pyloric botox injection post-operatively. This has significant long-term implications for both patients’ quality of life post-operatively and demands on over-stretched endoscopic services.
P-OGC84 Impact of routine feeding via jejunostomy after oesophagectomy
Authors: Khaw Rachel A , Macdonald Jill , Munro Samuel , Phillips Alexander W
Published: December 2021

Background

Oesophageal cancer is the 8th most common cancer worldwide, with oesophagectomy remaining the mainstay curative treatment, despite significant associated morbidity and mortality. Postoperative weight loss remains a significant problem and is directly correlated to poor prognosis. Measures such as the Enhanced Recovery After Surgery (ERAS) programme and intraoperative jejunostomy feed placement have looked to tackle this. Our aim was to investigate the impact of supplemental jejunostomy feed in practice on mortality, length of hospital stays and postoperative weight loss in a high-volume regional centre.

Methods

Patients undergoing oesophagectomy between January 2012 - December 2014 and January 2016 - December 2019 in a national tertiary oesophagogastric unit were included retrospectively. Variables measured included comorbidities, operation, histopathology, weights (pre- and post-operatively), length of hospital stay, postoperative complications and mortality. Survival data were analysed using R Studio, Inc.

Results

566 patients were included. Median age at diagnosis was 66 years (30-85). Majority of cases included were adenocarcinoma (72.6%), or squamous cell carcinoma (22.3%). Within the two study groups, severe weight loss > 10% of pre-operative weight was seen in 38.6% and 4.87% of patients discharged without and with jejunostomy feeds at 3 months, respectively. At 6 months, severe weight-loss was seen in 47.6% and 0.64% of patients discharged without and with jejunostomy feeds, respectively. Median length of stay was 15 days (7-92) and 12 days (6-338) for patients discharged without and with jejunostomy feeds, respectively. Overall median survival in patients discharged without jejunostomy was 52 months (p = 0.035), and in those discharged with jejunostomy, 48 months (p = 0.044).

Conclusions

Postoperative malnutrition has associated poor outcomes. Perioperative nutritional support, to include postoperative jejunal feeding post-discharge can reduce weight loss, and influence survival as well as length of hospital stay. Further randomised trials are needed in order to optimise recovery and morbidity in patients post-oesophagectomy.
P-OGC86 Textbook Outcome following Oesophagectomy for Oesophageal Cancer: An International Cohort Study
Authors:   Oesophagogastric Anastomosis Audit Collaborative
Published: December 2021

Background

Although textbook outcome (TO) has been proposed as a tool for the assessment of oncological surgical care, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess TO in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 - December 2018. TO was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with TO, and results are presented as odds ratio (OR) and 95% confidence intervals (CI95%).

Results

This study included 2,159 patients with oesophageal cancer, of whom 39.7% achieved a TO. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a TO for patients with oesophageal cancer, compared to other TO parameters. Multivariable analysis identified male gender, increasing Charlson comorbidity index, and higher AJCC T and N staging to be associated with a significantly lower likelihood of TO. After accounting for these factors, high volume centres (>50 cases/year; OR: 1.36, CI95%: 1.06 - 1.75, p = 0.015), presence of 24-hour on-call rota for oesophageal surgeons (OR: 2.11, CI95%: 1.33 - 3.35, p = 0.001) and radiology (OR: 1.56, CI95%: 1.08 - 2.26, p = 0.019), total minimally invasive esophagectomies (OR: 1.60, CI95%: 1.25 - 2.05, p < 0.001), and chest anastomosis above azygous (OR: 2.17, CI95%: 1.58 - 2.98, p < 0.001) were independently associated with a significantly increased likelihood of TO. 

Conclusions

TO is achieved in less than 40% of patients having oesophagectomy for cancer. Improvements in centralisation, hospital resources (i.e. daily 24-hour on-call esophagogastric surgeons and radiologists), access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve TO. Understanding how these individual parameters help improve quality of patient care should be the focus of future research.
P-OGC94 Outcomes of oesophagectomy post endoscopic mucosal resection
Authors: Yahya Muhammad Syafwan , Kennedy Andrew , Kennedy Raymond , McManus Damian , Harris Andrew , MacAulay Graeme
Published: December 2021

Background

Within developed nations, oesophageal adenocarcinoma has the greatest incidence of any solid organ tumour with number escalating on a yearly basis. A recent expert review by the AGA suggests that high grade Barrett’s dysplasia and intramucosal adenocarcinoma are better treated endoscopically rather than oesophagectomy and that endoscopic management is a reasonable alternative to oesophagectomy for selected patients with low risk pT1b tumours.. Risk factors for nodal involvement and recurrence have been suggested by Lee et al (1). This study aims to review the pathological and clinical outcomes following oesophagectomy post EMR.

Methods

Results

Conclusions

Whilst some low risk patients had residual tumour at oesophagectomy, these findings were similar to Nelson et al 3; recurrent/recurrent local tumour could be potentially managed by repeat EMR. The absence of nodal metastasis in this small series is consistent with the AGA recommendation of EMR as a reasonable alternative to oesophagectomy for patients with selected low risk pT1b tumors.
P-P02 Incidence and risk factors for chyle leak after pancreatic surgery: a systematic review and meta-analysis
Authors: Varghese Chris , Wells Cameron , Lee Shiela , Ammar Khaled , Pandanaboyana Sanjay
Published: December 2021

Background

The incidence of, and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery (ISGPS), remain unknown. 

Methods

MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 ISGPS definition. The primary outcomes were the incidence of overall and clinically-relevant chyle leak. A random-effects pairwise meta-analysis was used to identify risk factors where possible. 

Results

Thirty-five studies including 7083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% CI 5.6 - 8.2) and clinically-relevant chyle leak was 5.5% (95% CI 3.8 - 7.7). Pancreaticoduodenectomy, total pancreatectomy and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, 5.8% respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies.

Conclusions

The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 ISGPS definition is 6.8% and 5.5% respectively. Several risk factors for chyle leak were identified in the present review, however, larger high-quality studies are needed to more accurately define these risks.
P-P08 Towards effective analgesia in acute pancreatitis: a systematic review of randomised controlled trials
Authors: Thavanesan Navamayooran , White Sophie , Lee Shiela , Ratnayake Bathiya , Leeds John , Nayar Manu , Sharp Linda , Siriwardena Ajith , Drewes Asbørn , Capurso Gabriele , de Madaria Enrique , Windsor John , Pandanaboyana Sanjay
Published: December 2021

Background

The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. The present systematic review and meta-analysis aims to compare the efficacy of several analgesic modalities trialled in AP.

Methods

A systematic search of PubMed, MEDLINE and EMBASE was conducted up until June 2021, according to PRISMA Guidelines to identify all randomised control trials (RCTs) comparing analgesic modalities in AP.  The primary outcome measure was improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2.

Results

Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), placebo, local anaesthetic, epidural, paracetamol and metamizole. A weighted single-arm effects estimate showed global improvement in VAS across all modalities from baseline to day 2. On visual inspection, epidural analgesia appears to provide the greatest improvement in pain scores within the first 24hrs, however at 48hrs it was comparable to opiates. Within the first 24hrs, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant heterogeneity in pain-relief reporting with relatively small datasets per study.

Conclusions

Given the incidence of AP there is remarkable paucity of level 1 evidence to guide pain management. Epidural administration is most effective analgesic modality within the first 24hrs of AP. NSAIDs are an effective opiate sparing alternative during the first 24hrs.
P-P13 Long-term outcome after portal vein resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matched analysis
Authors: Russell James , Stevens Claire , Bhome Rahul , Karavias Dimitrios , Arshad Ali , Takhar Arjun , Armstrong Thomas , Primrose John , Green Brian , Hamady Zaed
Published: December 2021

Background

Portal vein resection (PVR) with pancreaticoduodenectomy (PD) is often performed to achieve clear margins for patients with vascular involvement in pancreatic ductal adenocarcinoma (PDAC). However, there is evidence to suggest that patients undergoing PVR often have more advanced cancers, therefore the impact of PVR on survival and recurrence remains unclear. The aim of this study is to assess overall (OS) and recurrence free (RFS) survival in patients who underwent PVR during PD, with particular attention to margin positivity.

Methods

A retrospective analysis was performed on 638 patients who underwent PD during a 12-year period. Exclusion criteria included PD for non-PDAC tumours, neoadjuvant chemotherapy or intra-operative radiotherapy. 374 patients were included in the study (90 PVR and 284 non-PVR). Patient characteristics and histopathological factors associated with OS and RFS were then evaluated using univariate and multivariate Cox regression analyses. 270 patients (90 PVR and 180 non-PVR), were matched by propensity score based on perineural invasion, pT and pN staging. The Kaplan-Meier method was used to calculate survival and log-rank tests.

Results

Resection margin positivity was associated with shorter OS and RFS (p < 0.0001), and the superior mesenteric vein (SMV) margin was the most significant risk factor for survival on competing risks analysis. Absent adjuvant chemotherapy, nodal metastasis and margin positivity were independent risk factors for OS and RFS on multivariate analysis. PVR was associated with higher intra-operative blood loss (p = 0.009), but was not associated with increased length of stay, complications or readmissions. PVR patients had increased pT staging, nodal metastasis and perineural invasion, however, there was no difference in OS (p = 0.551) or RFS (p = 0.256) between PVR and non-PVR after propensity matching.

Conclusions

Positive resection margins are associated with shorter survival times, and the SMV margin is the most significant prognostic indicator for overall survival and recurrence compared to other margins. PVR is a relatively safe procedure, however, it does not achieve the intended survival benefits of complete margin clearance. The impact on survival for margin positivity, particularly the SMV margin, and nodal metastasis should be considered when making decisions with regards to vein resection and adjuvant treatments.
P-P16 Management of acute pancreatitis in a busy district general hospital
Authors: Saldanha Simon , Joshi Aparna , Niaz Osamah
Published: December 2021

Background

Pancreatitis is a common surgical presentation and can be life threatening, with complications such as acute respiratory distress syndrome and necrosis occurring. Due to high hospital incidence, it is important to ensure patients are managed appropriately using available guidelines. This audit aims to assess the management of acute pancreatitis in a busy district general hospital and identify areas for improvement to better patient safety.

Methods

Only cases of acute pancreatitis were used in this audit. Case notes for the period between October and December 2020 were collected respectively. A data collection proforma was created using guidelines from the British society of gastroenterology for the management of acute pancreatitis. Data was then analysed using Excel.

Results

23% of cases had documented scoring, with Glasgow-Imrie the only scoring tool used.

41% had documented oxygen saturation.

33% had been reviewed by alcohol liaison team for pancreatitis secondary to high alcohol consumption.

No patients were given the guideline’s recommended rate of fluid resuscitation (5-10ml/kg/hr).

All patients had amylase/lipase in their blood profile.

80% of patients had antiemetics prescribed should they require them, whilst 95% of patients had opioids prescribed for analgesia.

50% of patients were given antibiotics despite them not being indicated.

18% were kept nil by mouth (NBM) whilst having abdominal pain.

Conclusions

Our results suggest that guidelines for acute pancreatitis are not adequately adhered to.

Many aspects of the guidance were not followed including documentation of oxygen saturation, antibiotic use, IV fluid resuscitation and alcohol liaison review for patients who required review.

We have developed a proforma to use for the management of acute pancreatitis to ensure that cases are managed in accordance with evidence-based literature and to make the management of these cases easier.

We will reaudit to analyse the effects of our intervention and determine whether there has been an improvement in the management of acute pancreatitis.
P-P17 Casting a Wider NET: Defining PEI in patients with Neuroendocrine Tumours using the 13C-MTG breath test
Authors: Hall Lewis , Powell-Brett Sarah , Bradley Elizabeth , Thompson Oscar , Smith Stacey , Vickrage Suzanne , Kemp-Blake Joanne , Shah Tahir , Roberts Keith
Published: December 2021

Background

Somatostatin-analogues (SSAs) are the first-line treatment of unresectable, symptomatic neuroendocrine tumours (NETs). However, SSAs inhibit pancreatic secretions which could lead to pancreatic exocrine insufficiency (PEI). There is, however, very limited data regarding the physiologic link between SSAs and PEI. PEI negatively impacts patient quality of life (QoL), nutritional status, and clinical outcomes. This is a prospective, observational, cohort study to establish the impact of SSAs on pancreatic exocrine function in patients with NETs, using the 13C-Mixed-Triglyceride (13C-MTG) breath test.

Methods

Adult patients commencing SSA therapy for NETs, were recruited from December 2020. Patients were excluded if they had a diagnosis of other pancreatic disease, history of upper-gastrointestinal surgery that may alter pancreatic function, or already on SSA therapy. The impact of SSAs on exocrine function was assessed using the 13C-MTG breath test. A quotient of 13CO2/12CO2 was measured by mass spectrometry and the cumulative percent dose recovered at 6 hours (cPDR) is reported. Secondary endpoints investigated were changes in patient weight and Vitamin D levels.

Results

Exocrine function reduced in all patients (n = 7) following SSA therapy (median reduction from baseline: -22.2%, range: -5.6- -42.1%; p = 0.018) (Figure 1). Vitamin D levels decreased in all but one patient (median decrease from baseline: -11.7%, range: -29.3-10%; p = 0.126). Change in patient weight did not show any significant change (median decrease from baseline: -0.69%, range: -4.26 – 3.6%, p = 0.933).

Conclusions

SSA therapy appears to have a consistent impact on exocrine function from early in the treatment course. This suggests that there is a widespread underestimation of PEI in this setting. Whether such decrease in exocrine function leads to weight loss remains to be seen. Further studies are required to confirm this work, determine the clinical relevance of this observation, and optimise medical therapy of PEI in this cohort. The 13C-MTG breath test is a feasible and acceptable measure of pancreatic exocrine function in patients treated with SSA therapy for NETs.
P-P25 Hot Axios stent removal following endoscopic pancreatic necrosectomy
Authors: Greaves Owain , Baron Ryan , Evans Jonathan , Raraty Michael , Mann Kulbir , Kok Khoon-Sheng , Ramesh Jayapal , Hughes Faye , Halloran Chris , Dunne Declan
Published: December 2021

Background

Symptomatic pancreatic pseudocysts or walled off necrosis following pancreatitis can be drained via a stoma from the collection to the GI tract, this is typically facilitated by endoscopic stents. These stents are left in-situ until the area has drained, this can take several months. The stent is then ideally removed endoscopically. Little is known about the consequences of failed endoscopic stent removal or factors contributing to this failure.  

Methods

Retrospective analysis of prospective data at LUHFT between 1st January 2018 and 31st December 2019 of patients receiving at least one Hot Axios stent for management of pancreatic collection. Normally distributed data were compared using Student’s two tailed T test, with non-parametric data compared using Mann-Witney U test, categorical data were analysed using Chi2 test

Results

131 patients were included in analysis, of which 74 were male with a median age of 56 years (IQR 46-66.5).  Failure of endoscopic removal (14 patients) was associated with a longer time to removal; 101 days (IQR 78-121) to first attempt vs. 49 days (IQR 19-104) to first endoscopic attempt where the stent was successfully retrieved endoscopically (p < 0.01). Surgical removal was undertaken in 6 patients, with significant morbidity in 2 of 6 patients. Overall 90-day mortality in patients undergoing Hot Axios stent placement was 8 of 131 (6%).

Conclusions

Endoscopic stent removal fails more frequently in patients where the stent has remained in situ for a long time before removal is attempted. Surgical removal of Hot Axios Stents is associated with significant morbidity, and this should be balanced against the as yet unknown consequences of leaving Hot Axios stent in-situ permanently.
P-P26 Post-laparotomy pain: the Rectus Sheath Pocket technique compared to other analgesic modalities
Authors: Dalli Rebecca , Abela JoEtienne
Published: December 2021

Background

Wound pain is a major cause of morbidity after laparotomy, leading to reduced mobility, poor respiratory effort, and delayed discharge. In our centre, we have developed a safe and effective post-operative analgesia technique that reliably delivers a continuous, stable infusion of local anaesthetic solution into a pocket superficial to the posterior rectus sheath.

Methods

Sixty-eight adult patients were enrolled in the study. Group A, n = 38 received rectus sheath catheter (RSC) analgesia and Group B, n = 30 received standard post-operative analgesia. The pain score on day 1 and total opioid dosage over the first 72 hours post-operatively were recorded. All patients were recruited from Mater Dei Hospital which is the main acute hospital in Malta. The patients who were recruited consecutively for the study group underwent elective or emergency laparotomies within a pancreatic-biliary firm. For the control group, patients underwent elective or emergency laparotomies under the care of other teams within the same surgical department. 

Results

Group A displayed significantly diminished mean pain scores (2.81±2.26 vs 4.66±2.86 p = 0.003) but no statistically significant reduction in cumulative opiate usage. On further subgroup analysis, patients over 65 years of age with RSC, displayed significantly less overall cumulative opiate usage (10.09±15.71 vs 25.79±32.97, p = 0.005). Few mild complications were recorded; catheter dislodgement (5), entrapment of catheter in wound sutures (1) and a wound hematoma (1) caused upon insertion.

Conclusions

Although inter-cohort demographics are consistent, case heterogeneity is acknowledged as a weakness of this endeavour. In adult patients, RSC has been demonstrated to be feasible, safe, and effective at diminishing pain scores in the postoperative period, especially so in the elderly population.
P-P29 The glycated haemoglobin (HbA1c) test is not a predictor of pancreatectomy specific complications or survival
Authors: Stevens Claire , Chan Charmaine Hu , Karavias Dimitrios , Takhar Arjun , Arshad Ali , Hamady Zaed , Armstrong Thomas , Pearce Neil , Primrose John
Published: December 2021

Background

The glycated haemoglobin (HbA1c) test is a venous blood test used as a diagnostic test for diabetes mellitus and to monitor glucose control in patients known to have diabetes. The test has been recommended by National Institute for Health Care Excellence (NICE) clinical guidelines in the pre-operative setting since 2016. The purpose of testing is to reduce perioperative morbidity and mortality by optimising management of blood glucose levels in the perioperative period. The aim of this study was to assess the prognostic value of HbA1c in pancreatic cancer patients treated with pancreaticoduodenectomy.

Methods

This is a retrospective analysis of a prospectively managed database of pancreatic resections at a single institution from January 2016 to December 2020. Included patients had confirmed pancreatic adenocarcinoma and underwent a pancreaticoduodenectomy with preoperative measurement of their HbA1c. Patients who were already prescribed insulin were excluded. Demographic data, survival, operative and perioperative details were collected. Included patient records were assessed for the incidence of postoperative complications in accordance with International Study Group of Pancreatic Surgery guidelines for pancreatic fistula, delayed gastric emptying and post pancreatectomy haemorrhage. An HbA1c greater than 41 was deemed elevated.

Results

There were 145 patients who met the inclusion criteria. The HbA1c level was normal in 101/145 (70%) and elevated in 44/45 (30%). The postoperative pancreatic fistula rate was 18% in the patients with a normal HbA1c and 23% in those with elevated HbA1c (p = 0.499). The rate of delayed gastric emptying was 21 and 23% in the patients with normal and elevated HbA1c respectively. There were five relaparotomies overall, one of these patients had an elevated preoperative HbA1c. There were no perioperative deaths. Overall survival was 31months (95%CI 27-35) with a normal preoperative HbAlc and 32months (95%CI 27-38) if elevated.

Conclusions

There is little doubt that the preoperative HbA1c is helpful in the package of preoperative assessment tests to optimise patients for surgery. However, the preoperative HbA1c level in patients planned for pancreaticoduodenectomy is not predictive of pancreaticoduodenectomy specific complications such as postoperative pancreatic fistula, delayed gastric emptying, relaparotomy or mortality. In addition, long-term overall survival is not influenced by an elevated preoperative HbAlc.
P-P56 Successful endovascular embolisation of a recurrent gastroduodenal artery aneurysm in a patient presenting with acute on chronic pancreatitis
Authors: Nair Dheepa , Jones Katie , Parameswaran Rajeev
Published: December 2021

Background

Pseudoaneurysms are recognised to be a serious complication of chronic pancreatitis.  Visceral artery aneurysms (VAA) can be difficult to determine and most commonly occur in the splenic or hepatic artery. Gastroduodenal artery pseudoaneurysms (GDA) have been reported to be the most common VAA following pancreatic surgery. We aim to outline the successful management of a patient with a recurrent 5.5cm GDA pseudoaneurysm following previous embolisation 2 years prior.

Methods

The 59yr old patient had a history of alcohol related necrotic pancreatitis with pseudocyst formation requiring percutaneous drainage in 2019. This was complicated by pseudoaneurysm formation requiring embolisation of the inferior pancreatico-duodenal artery and GDA.  In April 2021 they were readmitted with recurrent abdominal pain thought to be secondary to chronic pancreatitis and one episode of haematemesis.

Results

Endoscopy revealed inflammation of D1 with signs of recent mucosal bleeding with a recent abdominal ultrasound showing a 4.7x4.6cm apparent pseudocyst. A CT pancreas was performed to assess the pseudocyst however an incidental pseudoaneurysm at the pancreatic head with a sac measuring 5.5cm in diameter and contrast material measuring 3cm in diameter was present. Peripancreatic and retroperitoneal inflammation indicative of acute on chronic pancreatitis. The patient underwent embolisation of the recurrent GDA pseudoaneurysm successfully with no more filling of the previously seen pseudoaneurysm and was safely discharged.

Conclusions

Recurrent GDA pseudoaneurysms are a very rare complication of recurrent pancreatitis, however should be considered in patients presenting severe epigastric pain with a history of previous pseudoaneurysms.
P-P57 The first experience of intraoperative radiotherapy for pancreatic cancer in the UK
Authors: Bhome Rahul , Dimitrios Karavias , Tom Armstrong , Hamady Zaed , Ali Arshad , John Primrose , Pearce Neil , Arjun Takhar
Published: December 2021

Background

Intraoperative radiotherapy (IORT) involves giving a targeted single fraction of high dose radiation to the resection bed. The main advantages are exclusion of vulnerable structures from the radiation field and ability to direct the electron beam to threatened margins.  IORT in pancreatic cancer is not new, with Japanese centres reporting series from the 1970s. Early reports were exciting, suggesting that IORT was useful in reducing visceral pain, achieving local control and improving survival in locally advanced and unresectable patients. However, paucity of randomised trials in the ensuing decades has limited its widespread adoption.

Methods

With funding from the PLANETS charity (www.planetscharity.org), University Hospitals Southampton acquired a Mobetron 2000 linear accelerator (IntraOp, USA) in 2016. Testing was done at the National Physical Laboratory (Teddington, UK) over two months to collect beam data and ensure consistency in treatment delivery. Staff training included visits to the Heidelberg Cancer Centre and several dry runs. Inclusion criteria were: (i) patients with pancreatic head adenocarcinomas; (ii) threatened vascular margins; (iii) WHO performance status 1-2; (iv) no evidence of distant metastasis.

Results

Nineteen patients had pancreaticoduodenectomy (traditional or pylorus preserving) combined with IORT. Median age was 66 (42-81) years. Median ASA grade was 2 (2-3). 16/19 had locally advanced pancreatic cancer and 18/19 had neoadjuvant chemotherapy. Median IOERT dose was 15 (10-15) Gy, energy 7.5 (6-12) MeV, to a mean depth of 1.6 +/- 0.8 cm, with median cone size 5 (4-6) cm and bevel angle 15 (0-30) degrees. All tumours were pT1-T3 and 10/19 had positive regional nodes. 10/19 were R1 resections, with 4/19 specimens exhibiting vascular invasion and 6/19 perineural invasion. Mean operating time (including IOERT) was 534 +/- 77 min. Median length of stay was 8.5 (6-41) days. 30-day mortality was zero. 6/19 patients had post-operative complications (Clavien-Dindo 1-2 only), with clinically detectable pancreatic fistula in 1/19.

Conclusions

This is the first UK experience of IORT for pancreatic cancer, showing that this treatment modality is safe and feasible. With the appropriate expertise, an IORT service can be implemented within 12 months of acquiring the Mobetron system. We hope that these data will encourage other UK and European HPB units to consider setting up regional IORT services, such that larger scale prospective trials can be initiated to demonstrate its efficacy.
Comparative cohort study of Duhamel and endorectal pull-through for Hirschsprung’s disease
Authors: Davidson Joseph R. , Mutanen Annika , Salli Malla , Kyrklund Kristiina , De Coppi Paolo , Curry Joe , Eaton Simon , Pakarinen Mikko P.
Published: December 2021

Background

There are limited data available to compare outcomes between surgical approaches for Hirschsprung’s disease. Duhamel and endorectal pull-through (ERPT) are two of the most common procedures performed worldwide.

Methods

Objective outcomes were compared between contemporary cohorts (aged 4–32 years) after Duhamel or ERPT using case–control methodology. Data were collected using prospectively administered standardized questionnaires on bowel and bladder function and quality of life (Pediatric Quality of Life Inventory, Short form 36 and Gastrointestinal Quality of Life Index). Patients were compared in two age groups (18 years and younger and older than 18 years) and reference made to normative control data. Multivariable analysis explored factors associated with poor outcomes.

Results

Cohorts were well matched by demographics, disease characteristics and incidence of postoperative complications (120 patients who underwent Duhamel versus 57 patients who had ERPT). Bowel function scores were similar between groups. Patients who underwent Duhamel demonstrated worse constipation and inferior faecal awareness scores (P < 0.01 for both age groups). Recurrent postoperative enterocolitis was significantly more common after ERPT (34 versus 6 per cent; odds ratio 15.56 (95 per cent c.i. 6.19 to 39.24; P < 0.0001)). On multivariable analysis, poor bowel outcome was the only factor significantly associated with poor urinary outcome (adjusted odds ratio 6.66 (95 per cent c.i. 1.74 to 25.50; P = 0.006)) and was significantly associated with markedly reduced quality of life (QoL) in all instruments used (P < 0.001 for all). There were no associations between QoL measures and pull-through technique.

Conclusion

Outcomes from Duhamel and ERPT are good in the majority of cases, with comparable bowel function scores. Constipation and impaired faecal awareness were more prevalent after Duhamel, with differences sustained in adulthood. Recurrent enterocolitis was significantly more prevalent after ERPT. Clustering of poor QoL and poor functional outcomes were observed in both cohorts, with seemingly little effect by choice of surgical procedure in terms of QoL.
Concussion susceptibility is mediated by spreading depolarization-induced neurovascular dysfunction
Authors: Parker Ellen , Aboghazleh Refat , Mumby Griffin , Veksler Ronel , Ofer Jonathan , Newton Jillian , Smith Rylan , Kamintsky Lyna , Jones Casey M A , O’Keeffe Eoin , Kelly Eoin , Doelle Klara , Roach Isabelle , Yang Lynn T , Moradi Pooyan , Lin Jessica M , Gleason Allison J , Atkinson Christina , Bowen Chris , Brewer Kimberly D , Doherty Colin P , Campbell Matthew , Clarke David B , van Hameren Gerben , Kaufer Daniela , Friedman Alon
Published: December 2021

The mechanisms underlying the complications of mild traumatic brain injury, including post-concussion syndrome, post-impact catastrophic death, and delayed neurodegeneration remain poorly understood. This limited pathophysiological understanding has hindered the development of diagnostic and prognostic biomarkers and has prevented the advancement of treatments for the sequelae of mild traumatic brain injury.

We aimed to characterize the early electrophysiological and neurovascular alterations following repetitive mild traumatic brain injury and sought to identify new targets for the diagnosis and treatment of individuals at risk of severe post-impact complications. We combined behavioural, electrophysiological, molecular, and neuroimaging techniques in a rodent model of repetitive mild traumatic brain injury. In humans, we used dynamic contrast-enhanced MRI to quantify blood–brain barrier dysfunction after exposure to sport-related concussive mild traumatic brain injury.

Rats could clearly be classified based on their susceptibility to neurological complications, including life-threatening outcomes, following repetitive injury. Susceptible animals showed greater neurological complications and had higher levels of blood–brain barrier dysfunction, transforming growth factor β (TGFβ) signalling, and neuroinflammation compared to resilient animals. Cortical spreading depolarizations were the most common electrophysiological events immediately following mild traumatic brain injury and were associated with longer recovery from impact. Triggering cortical spreading depolarizations in mild traumatic brain injured rats (but not in controls) induced blood–brain barrier dysfunction. Treatment with a selective TGFβ receptor inhibitor prevented blood–brain barrier opening and reduced injury complications. Consistent with the rodent model, blood–brain barrier dysfunction was found in a subset of human athletes following concussive mild traumatic brain injury.

We provide evidence that cortical spreading depolarization, blood–brain barrier dysfunction, and pro-inflammatory TGFβ signalling are associated with severe, potentially life-threatening outcomes following repetitive mild traumatic brain injury. Diagnostic-coupled targeting of TGFβ signalling may be a novel strategy in treating mild traumatic brain injury.
Next-generation antibody-based therapies in neurology
Authors: Ruck Tobias , Nimmerjahn Falk , Wiendl Heinz , Lünemann Jan D
Published: December 2021

Antibody-based therapeutics are now standard in the treatment of neuroinflammatory diseases, and the spectrum of neurological diseases targeted by those approaches continues to grow. The efficacy of antibody-based drug platforms is largely determined by the specificity-conferring antigen-binding fragment (Fab) and the crystallizable fragment (Fc) driving antibody function. The latter provides specific instructions to the immune system by interacting with cellular Fc receptors and complement components. Extensive engineering efforts have enabled tuning of Fc functions to modulate effector functions and to prolong or reduce antibody serum half-lives. Technologies that improve bioavailability of antibody-based treatment platforms within the CNS parenchyma are being developed and could invigorate drug discovery for a number of brain diseases for which current therapeutic options are limited. These powerful approaches are currently being tested in clinical trials or have been successfully translated into the clinic. Here, we review recent developments in the design and implementation of antibody-based treatment modalities in neurological diseases.
Identity-Based Encryption With Continuous Leakage-Resilient CCA Security From Static Complexity Assumption
Authors: Zhou Yanwei , Wang Zhaolong , Qiao Zirui , Wang Ying , Yang Bo , Mu Yi , Zhang Mingwu
Published: December 2021

Although a large number of provably secure cryptographic primitives have been proposed in the literature, many of these schemes might be broken in practice because of various leakage attacks. Therefore, the leakage resilience should be considered in designing these primitives. However, in identity-based cryptography, most of the existing leakage-resilient identity-based encryption (IBE) schemes suffer some limitations: they either resist the leakage attacks in the selective identity security model or achieve the chosen-ciphertext attack (CCA) security based on a non-static assumption. In this paper, an IBE scheme with adaptive leakage-resilient CCA security is proposed, and its security is rigorously proved in the random oracle model under a classic static complexity assumption, e.g. decisional bilinear Diffie–Hellman assumption. In our construction, all elements of ciphertext are randomly distributed in the adversary’s view. Hence, the adversary cannot obtain any useful information of the user’s private key from the given ciphertexts. Moreover, a unique property of our construction is that the leakage parameter is independent of the plaintext space, which contributes a better leakage rate.
Quantitative perfusion assessment of gastric conduit with indocyanine green dye to predict anastomotic leak after esophagectomy
Authors: Ishikawa Yoshitaka , Breuler Christopher , Chang Andrew C , Lin Jules , Orringer Mark B , Lynch William R , Lagisetty Kiran H , Wakeam Elliot , Reddy Rishindra M
Published: December 2021

Impaired gastric conduit perfusion is a risk factor for anastomotic leak after esophagectomy. The aim of this study is to evaluate the feasibility of intraoperative quantitative assessment of gastric conduit perfusion with indocyanine green fluorescence angiography as a predictor for cervical esophagogastric anastomotic leak after esophagectomy. Indocyanine green fluorescence angiography using the SPY Elite system was performed in patients undergoing a transhiatal or McKeown esophagectomy from July 2015 through December 2020. Ingress (dye uptake) and Egress (dye exit) at two anatomic landmarks (the tip of a conduit and 5 cm from the tip) were assessed. The collected data in the leak group and no leak group were compared by univariate and multivariable analyses. Of 304 patients who were evaluated, 70 patients developed anastomotic leak (23.0%). There was no significant difference in patients’ demographic between the groups. Ingress Index, which represents a proportion of blood inflow, at both the tip and 5 cm of the conduit was significantly lower in the leak group (17.9 vs. 25.4% [P = 0.011] and 35.9 vs. 44.6% [P = 0.019], respectively). Ingress Time, which represents an estimated time of blood inflow, at 5 cm of the conduit was significantly higher in the leak group (69.9 vs. 57.1 seconds, P = 0.006). Multivariable analysis suggested that these three variables can be used to predict future leak. Variables of gastric conduit perfusion correlated with the incidence of cervical esophagogastric anastomotic leak. Intraoperative measurement of gastric conduit perfusion can be predictive for anastomotic leak following esophagectomy.
Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge
Authors: Allard Ludovic , Bernhard Benedikt , Windecker Stephan , Valgimigli Marco , Gräni Christoph
Published: December 2021

Although the management of ischaemic heart disease has markedly improved over the last decades, left ventricular thrombus remains a serious finding in patients with myocardial infarction. Routine diagnostic detection of left ventricular thrombus relies mainly on echocardiography; however, cardiac magnetic resonance has emerged as a method with higher diagnostic accuracy, while cardiac computed tomography angiography represents a valuable alternative modality. To reduce the left ventricular thrombus-associated morbidity and mortality, optimal selection of anticoagulation is warranted after balancing the risk of bleeding. In this review, we will discuss contemporary diagnostic modalities to detect left ventricular thrombus in ischaemic heart disease and summarize evidence on risk stratification and therapy. In addition, we propose a novel diagnosis, follow-up imaging, and treatment algorithm. Further, we identify knowledge gaps at different levels to address emerging research questions and to refine the design of future studies aiming to improve the management of patients in this clinical setting.