bluuebunny/crossref_metadata_2025 huggingface dataset:
OGBN P02 Longer term symptom control following revision anti-reflux surgery: a cohort of 379 patients
Authors: Krishnan Sailakshmi , Falk Gregory
Published: November 2023

Background

Symptom recurrence after primary hiatus hernia surgery is an established problem and revision anti-reflux surgery may be indicated in select cases of recurrence after primary surgery. Previous studies on this subject are of small number and often lack objective measures. Our aim is to review the long term post operative outcomes and assess the impact of revisional anti reflux surgery on symptom improvement and quality of life measures.

Methods

A prospectively maintained single-surgeon database of revisional hiatus hernia surgery from 1992 to 2022 was retrospectively evaluated. The results of the pre operative assessments were collated to identify the symptomatic, anatomical and physiological indications. Validated scoring systems including GIQLI, Visick, Dakkak and Reflux Symptom Index scores were compared pre-operatively and post-operatively. Post-operative GIQLI scores were measured in the first 12 months (short term), 12 to 36 months (medium term) and after 36 months (long term) in order to obtain a trend in patient reported outcomes. Questions assessing heartburn, dysphagia, and regurgitation were analysed to determine progress of these specific symptoms.

Results

The dataset consisted of 379 patients, of whom 59% were female. The average age at the time of first revisional surgery was 59 years (range 19-91). Laparoscopic surgery was performed in 90% of primary operations compared to 68% of revision operations. There was overall improvement in outcomes as demonstrated in this table. Additionally, evaluation of symptoms specific questions of the GIQLI showed a statistically significant improvement in dysphagia scores in the long term category (p = 0.0210).

Conclusions

There is a global improvement in long term control of reflux and dysphagia symptoms following revision hiatus hernia surgery showed. However, volume regurgitation symptoms were not shown to be consistently improved post operatively. This may be due to an underlying motility disorder in these patients or the potential of dysmotility caused by revision surgery from injury to the vagus nerve. Caution should be exercised when considering revision anti reflux surgery in this patient cohort.
OGBN P05 Specialist Nurse-Led Reflux Clinic – Streamlining the pathway to specialist care for gastro-oesophageal reflux disease
Authors: Adwan Hussamuddin , Davis Heather , Aburrous Mohamed , Maitland Louise , Goldsmith Louise , Penhaligon Hannah , Clarke Michael
Published: November 2023

Background

Gastro-oesophageal reflux disease (GORD) is a common condition that can have a significant impact on patients’ quality of life and be associated with serious complications. Our institution offers daycase laparosopic anti-reflux surgery to patients with severe GORD or those refractory to medical management. However, the referral pathway is often prolonged, due to multiple investigations under gastroenterology or the long waiting list for outpatient appointments. A nurse-led reflux clinic (NLRC), with surgeon oversight, was therefore developed to facilitate earlier access to secondary care assessment and investigation, thus aiming to reduce the ultimate time to consultant surgeon decision making.

Methods

A standardised electronic ‘tick box’ proforma was developed for completion by the upper GI nurse specialists, incorporating common and atypical symptoms, Eckardt score, ‘red flag’ symptoms, weight, comorbidity, investigation results and free-text. Appropriate further investigations were selected and a clinic outcome was coded electronically to generate an electronic patient letter, thus requiring no secretarial support. Surgeon oversight was provided by the lead investigator and following completion of investigations (e.g. oesophageal physiology) patients were booked to the next available Consultant Upper GI surgeon clinic. Data on patient satisfaction was collated using a validated questionnaire and referral times also recorded.

Results

64-referrals to the NLRC between September 2021 and September 2022. Median waiting time to first appointment was 10 weeks (range 2.7 - 28.4) and 32 weeks to decision making (range 4.4 - 87.1). This was compared with 31-referrals prior to November 2020 with median waiting time to the first appointment of 7 weeks (range 0.3 - 124.7), and to decision making of 39 weeks (range 12.1 - 125.6). Completed satisfaction surveys showed more than 95% of patients were either “very satisfied” or “satisfied” with the overall care, explanation of tests, how they were treated, knowledge and skill of nurse and the timing of consultation.

Conclusions

Although there was no significant difference in the waiting time to the first appointment, NLRC helped reduce the overall waiting time to decision making. Introduction of a specialist nurse led-reflux clinic, with surgeon oversight, offers an effective solution for managing patients that may require anti-reflux surgery in a more timely manner, with good patient satisfaction.
OGBN P06 Co-location of pulmonary abnormalities on high resolution CT imaging and pulmonary microaspiration reflux scan: Suggests a causative relationship
Authors: Goonawardhana Dulani , Khoma Oleksandr , Van der Wall Hans , Burton Leticia , Falk Gregory
Published: November 2023

Background

The relationship between micro-aspiration of refluxate as a form of gastro-oesophageal reflux disease (GORD) and pulmonary diseases including bronchiectasis and lung fibrosis has been circumstantially suggested but not proven. Clarification of the role of GORD and microaspiration in pulmonary disease may enable targeted therapies. This study aims to determine whether there is a relationship between anatomical location of aspiration of radiological tracer on scintigraphic imaging and changes associated with pulmonary disease on high resolution computed tomographic imaging of the lung (HRCT-L).

Methods

Data were obtained from a prospectively populated database of patients with treatment resistant typical and atypical GORD and suspected reflux pulmonary microaspiration. Patients who underwent microaspiration studies and had concurrent HRCT-L for chest symptoms were included. Modified novel digital technique of reflux pulmonary microaspiration scintigraphy using a previously validated technique was performed to evaluate the possibility of significant GORD or extra-oesophageal symptoms, including typical symptoms such as heartburn and reflux and atypical symptoms such as throat symptoms, cough, globus, mucous, throat clearing, dysphonia and recurrent respiratory infections. HRCT-L was obtained in clinically indicated patients and compared with scintigraphic findings.

Results

Pulmonary reflux microaspiration scanning was performed in 121 patients (75% female, 25% male). The mean age was 67 years (range: 31 – 91 years). All patients demonstrated reflux microaspiration on scintigraphy in the supine delayed phase and all had intermittent or continuous full column gastro-oesophageal reflux. Lung parenchymal changes were apparent in 66 of 73 patients who underwent HRCT-L. Fibrotic changes were demonstrated in 51% of patients and bronchiectactic changes in 46%. Correlation at anatomical lobar levels with areas of aspiration of isotope on scintigraphic imaging was seen in 97% of fibrosis patients and 85% of bronchiectasis patients.

Conclusions

Modified reflux pulmonary microaspiration scintigraphy demonstrated the presence of pulmonary aspiration on delayed imaging. This is the first imaging technique with the ability to confirm the presence of lung aspiration of gastric content. Given the large proportion of cases showing lobar co-location of pulmonary abnormality on HRCT-L, this study indicates a strong relationship between aspiration of refluxate and parenchymal lung changes associated with pulmonary diseases such as IPF and bronchiectasis. There may be a significant role for modified technique scintigraphy to accurately diagnose the presence of reflux aspiration, allowing further research into pathogenesis and management of pulmonary disease.
OGBN P07 Is Emergency Cholecystectomy safe in the oldest old? A 10-year, single institution Retrospective study
Authors: Ahuja Manish , Soggiu Fiammetta , Goutham Meera , Drymousis Panagiotis , Pore Naresh , Jawad Zaynab , Abdalla Sala , Raje Durgesh , Sheth Hemant
Published: November 2023

Background

The incidence and severity of presentation of cholelithiasis or its complications increases with increasing age. Higher risks of morbidity, longer hospital stay, and mortality are the potential challenges to this emergency procedure in this cohort. There is little UK based data citing outcomes of emergency surgery in this group of population.

The aim of this study was to evaluate the safety of emergency cholecystectomy in patients aged 75 and above.

Methods

Data of consecutive patients aged 75+ undergoing an emergency laparoscopic cholecystectomy for acute cholecystitis at a London district general hospital between January 2013 and April 2023 was analysed. Outcomes of interest were time to procedure, length of hospital-stay, nature of complications and post-operative mortality.

Results

123 patients were included. Median age was 80 years (Range 75-93). Median time from presentation to surgery was 4 days (Range 1-45), overall length of stay was 10 days (Range 1-62), and post-procedure stay was 6 days (Range 1-62). Conversion rate was 5% (n=6), overall complication rate was 11% (n=14) and, 4% (n=5) Clavien-Dindo grade 3-4 complications were observed. Bile leak was observed in 2 patients needing ERCP and re-admission rates were 8% (n=10). One patient died within 90 days postoperatively for reasons unrelated to the surgery.

Conclusions

This study shows that an emergency laparoscopic cholecystectomy has acceptable complication and readmission rates, and it should be considered even in the elderly population. Biologic age rather than demographic age influences the perioperative risks and decision for surgery should be multidisciplinary with risks and benefits carefully weighed with the patient case by case.
OGBN P12 Use of Computed Tomographic Scan in Diagnosis and Management of Acute Pancreatitis; A Clinical Audit
Authors: Moti Terngu , Alwani Omneya , Baltatzis Minas , Alasmar Mohamed
Published: November 2023

Background

Acute pancreatitis is a frequently encountered emergency surgical condition, with computed tomography (CT) scans being commonly used for diagnosis and management. This audit was done in an NHS Hospital in Northwest, England with the aim to assess the utilization of CT scans in the diagnosis and management of acute pancreatitis in accordance with local policy.

Methods

Data were collected from all patients admitted with acute pancreatitis between October 2022 and March 2023. The focus of the investigation was on patients who underwent CT scans, with the objective of identifying the indications for their usage.

Results

The audit included a total of 53 patients (mean age 52.75 years, almost equal gender distribution). 64.2% had clinical pancreatitis (typical symptoms and diagnostic amylase levels), while 35.8% did not. 42 patients (79.2%) underwent CT scans. Of these scans, 42.9% were performed in patients without diagnostic amylase levels, 14.3% to rule out complications after 3 days, 9.5% due to a history of pancreatic complications, 1 was based on strong suspicion of another pathology, and another for diagnosing a common bile duct stone in a patient with an MRI incompatible pacemaker. Furthermore, 12 (28.5%) of the scans done were considered unnecessary.

Conclusions

The findings indicate that approximately 8 out of 10 patients with acute pancreatitis underwent at least one CT scan during their hospitalization. However, a significant proportion (28.5%) of these scans were deemed unnecessary.
OGBN P17 Day-Case Fundoplications: a Coastal DGH’s Transition
Authors: Hale Emily , Lowe Rosemary , Platt Timothy
Published: November 2023

Background

Torbay Hospital has a well-established day surgery unit, treating over 9,000 patients a year. Day-case laparoscopic fundoplications (LF) are increasingly common, and equally safe in comparison to inpatient procedures. The purpose of this study was to analyse the difference between day-case and inpatients, to determine reasons for stay, and subsequently facilitate more day-cases in Torbay Hospital.

Methods

This is a retrospective study using electronic records to analyse admission, surgery and 30-days recovery. Patients were identified between 1st January 2020 and 1st April 2023 by searching the following OPCS 4.10 codes in operation notes: G231 – G234, G241 - G243 & G245 (hiatus/oesophageal/diaphragmatic hernia repair). This identified 96 procedures, 1 of which was immediately excluded as incorrectly identified. Parameters examined were as follows: indication for surgery, elective or emergency, length of stay post operatively, reason for stay, plan for daycase or inpatient stay, readmission within 30 days and reason, and hiatus hernia grade.

Results

19 of 95 procedures were day-cases: 5% of cases in 2020, 2021 22%, 2022 19% and 83% so far in 2023. All day-cases were elective, whilst 9% of inpatients were emergency. Indications for day-cases were reflux (79%), atypical symptoms (16%) and stricture (5%). Inpatient indications were: reflux (39%), gastric volvulus (23%), hiatus hernia (12%), atypical (7%) and other (19%). Average Hill Classification of hiatus hernia was type-I in day-case and type-III in inpatients. 4 (21.1%) of day-case patients were readmitted (30 days), 13 (17.3%) of inpatients. The difference was 3.8% (95%CI -12.72 to 24.12), SE for percentage difference 9.2, p0.69.

Conclusions

The majority of LF at Torbay Hospital have been inpatient, although day-cases are increasing. Successful day-cases were always elective, of less severe hiatus hernias, and more commonly for symptomatic reflux as opposed to other pathology. There is no significant difference in the rates of readmission between the two groups. These indicate a pattern to identify future day-case LF and improve our service.
OGBN P23 Diagnosing and mapping Barrett's oesophagus: a need to be better
Authors: Asarbakhsh Mariam , Singh Gautam , McDonald Claire , Olejnik Hannah , Megson Tyler , Verma Harsh , Saha Arin
Published: November 2023

Background

The diagnosis of Barrett's oesophagus is made by endoscopic assessment of the oesophageal epithelium and histopathological confirmation of intestinal metaplasia on oesophageal biopsies. There are clear standards for the diagnosis of Barrett's oesophagus described by the British Society of Gastroenterologists (BSG). It is vital to maintain these standards to ensure accuracy of diagnosis (to prevent both over-diagnosis and under-diagnosis) and to ensure that conversion to dysplasia or neoplasia is not missed. This study aimed to assess the quality of Barrett's surveillance at our institution and implement changes in our service to improve diagnosis.

Methods

All patients who were due to have Barrett's surveillance endoscopy in 2022 were identified from our electronic hospital waiting lists. Initial endoscopy reports, where the Barrett's was diagnosed, were obtained and assessed for quality of adherence to BSG standards, such as image capture, number of biopsies, recording of Prague classification, use of high-definition screens and use of adjuncts (such as infacol or acetic acid). Histopathological reports were obtained and assessed for correlation with endoscopic findings.

Results

192 patients were identified for this study. All had Barrett's oesophagus diagnosed between 2016 and 2020, either on endoscopic grounds, histopathological suggestion of intestinal metaplasia, or both. A total of 29 different endoscopists (including consultant gastroenterologists, surgeons, trainees, nurse endoscopists and endoscopists from outsourcing companies) had performed the primary diagnostic scope in this cohort. 55 patients (29%) did not have any images captured and recorded on their endoscopy report. 36 patients (19%) did not have a Prague classification recorded. Only 127 patients (66%) had intestinal metaplasia on biopsies. p53 status was not recorded in any case.

Conclusions

This study highlights several deficiencies in the current practice of diagnosis of Barrett's oesophagus and these findings may be replicated in other units. These data have been used to develop a wide-ranging quality improvement programme for Barrett's surveillance, including dedicated Barrett's lists shared amongst a small number of experienced endoscopists, use of a high resolution scope and camera system, image capture and appropriate 'pointing' of procedures to allow enough time for accurate mapping and use of endoscopic adjuncts.
OGBN P24 Primary symptom indication can be a predictor of outcomes in revisional anti-reflux surgery
Authors: Krishnan Sailakshmi , Falk Gregory
Published: November 2023

Background

Symptom recurrence after primary hiatus hernia surgery is an established problem and revision anti-reflux surgery may be indicated in select cases of recurrence after primary surgery. Previous studies on this subject are of small number and often lack objective measures. Our aim is to assess the relationship between primary symptom indication and a variety of objective and subjective post operative outcomes.

Methods

A prospectively maintained single surgeon database of revisional hiatus hernia surgery from 1992 to 2022 was retrospectively evaluated. This was a consecutive cohort of adults greater than 18 years of age. The symptomatic, anatomical, and physiological indications for surgery were reviewed. The symptoms described by patients were grouped into four categories: typical reflux, volume, obstructive and gastric motility symptoms. The intraoperative findings and post operative outcomes were analysed. The dataset consisted of 379 patients, of whom 59% were female. The average age of this cohort at the time of primary revisional surgery was 59 years (range 19-91).

Results

Intraoperative findings of the revision operations found that 32% had a large hiatus hernia, 30% had a small hernia, 16% had a moderate hernia, 8% had a very large hernia. Patients who initially presented with volume symptoms appeared more likely to have two or more revision operations than patients who presented with no volume symptoms. Symptom score improvement was seen in reflux and dysphagia symptoms following revisional surgery. No significant improvement was seen in volume symptoms. Symptom focused questions in the GIQLI score demonstrated a statistically significant improvement in dysphagia symptoms 12 months post surgery (p=0.021).

Conclusions

Patients presenting initially with volume symptoms may be more likely to require multiple revision operations. This could be either due to an undiagnosed underlying motility disorder or advanced severity at presentation. Consideration of an alternative procedure such as roux-en-y gastric bypass could be entertained in this group.
OGBN P28 Accuracy of Barium Swallow and PH Manometry on Pre-operative Anti-reflux surgery
Authors: Nagarajan Ashitha , Goutham Meera , Jagtiani Minal , Pore Naresh , Sheth Hemant , Raje Durgesh
Published: November 2023

Background

Fundoplication is one of the common surgical procedures offered to patients who have not responded to medical or conservative treatment for Gastroesophageal-Reflux-Disease.Within our trust routine-PH manometry,barium swallow and OGD are preferred pre-op investigations.According to the guidelines set forth by SAGES(Society of American Gastrointestinal and Endoscopic Surgeons)-PH manometry and endoscopy are recommended as the preferred methods for pre-operative assessment.PH manometry is considered the gold standard for detecting reflux and dysmotility.Our objective is to evaluate and compare the local practice with published literature on identifying the accuracy of pre-operative barium swallow and ph manometry in diagnosing reflux and dysmotility.

Methods

A retrospective review of electronic medical records of patients who had Nissen fundoplication at Ealing Hospital between January2017-December2022 was included in the study. Among these, patients who had both pre-operative assessments - barium swallow and Ph manometry were included in the cohort. Initial data was retrieved from the Surgical operating service list and was further analyzed with the help of EPRO ( Electronic information provider) for information on Barium swallow, Ph manometry studies, and postoperative outcome.

Results

In a study of 54 Nissen Fundoplication patients (mean age M&F 58), 25 underwent pH manometry and barium swallow- Concordant positive results were found in 13 patients (52%), indicating reflux. Discordant results occurred in 11 patients (44%) with positive manometry but negative barium swallow, favoring pH manometry's sensitivity. Of the 25 patients analyzed, 20 (80%) had good symptom control, while 3 (12%) experienced symptom recurrence, and 2 (8%) missed follow-ups. Barium swallow missed 8 dysmotility cases, while pH manometry missed 4. Among 46 patients with detected hiatus hernia by OGD, only 26 (54%) were accurately diagnosed using barium swallow.

Conclusions

Our study demonstrated that Ph manometry is a reliable pre-operative assessment tool for anti-reflux surgery, achieving 100% accuracy in detecting reflux compared to only 55% accuracy with barium swallow. With dysmotility, Ph manometry showed better results of 67% whereas barium swallow identified only 33%. Barium swallow should be used as an additional investigation for failed pH studies and reflux-related dysphagia symptoms. It can also be valuable in post-operative cases to evaluate wrap position and potential complications due to tightness. These findings were presented at the local surgical audit meeting, and future cycles will focus on guideline compliance assessment.
OGBN P34 Telemedicine clinics are a safe and feasible alternative to preoperative face-to-face assessments for day case laparoscopic cholecystectomy surgery: a retrospective cohort study
Authors: Siraj Lakha Adil , Urbonas Tomas , King Emily , Pepes Sophia , Ceresa Carlo , Udupa Venkatesha , Soonawalla Zahir , Silva Michael A , Gordon-Weeks Alex , Reddy Srikanth
Published: November 2023

Background

The telemedicine clinic for follow ups after minor surgical procedures in general surgery is now ubiquitously considered a standard of care. However, this method of consultation is not the mainstay for preoperative assessment and counselling of patients for common surgical procedures such as laparoscopic cholecystectomy. The aim of this study was to assess the safety of assessing and counselling patients in the telemedicine clinic without a physical encounter for laparoscopic cholecystectomy.

Methods

We conducted a retrospective analysis of patients who were booked for laparoscopic cholecystectomy for benign gallbladder disease via general surgery telemedicine clinics from March 2020 to November 2021. The primary outcome was the cancellation rate on the day of surgery. The secondary outcomes were complication and readmission rates. Statistical analysis was done using JASP 0.16.2 software.

Results

We identified 206 cases booked for laparoscopic cholecystectomy from telemedicine clinics. 6.8% of patients had surgery cancelled on the day of surgery. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. Severe postoperative adverse events (equal or higher than grade 3) were observed in 1% of patients. 30-day readmission rate was 11%.

Conclusions

Our series showed that it is feasible to assess and counsel patients for laparoscopic cholecystectomy remotely with a minimal cancellation rate on the day of operation. Further work is needed to understand the effect of remote consultations on patient satisfaction, environmental impact, and healthcare economics to support its routine use in general surgery.
OGBN P42 Surgical innovation in the NHS: the role of local hospitals, NICE and the health research authority
Authors: Wallis Lucy , Cousins Sian , Blazeby Jane
Published: November 2023

Background

Innovation in surgery is key to advancing care. Innovation, however, may carry risk. Oversight of innovation therefore is needed to ensure transparent patient consent, learning from adverse events and efficient decision making for innovation scaling-up, non-adoption or abandonment. In the UK this may be regulated by an ethically approved research protocol or by committees in NHS local hospitals. The National Institute of Clinical Excellent (NICE) makes recommendations for appropriate oversight but little is known about interactions between local NHS hospital committees and NICE. We explored decision-making about surgical innovation in the local NHS committees in relation to NICE guidance.

Methods

A prospective study of five hospitals in England was undertaken between February 2022 and March 2023. Decisions made by the local new procedures committees and meeting minutes were all reviewed. Where NICE guidance was available this was compared to the local hospital decision about the new procedure. Where no guidance was available decisions were recorded and analysed based on available evidence and practice. Whether hospitals referred the innovation to NICE was also recorded.

Results

In the 12 month period 38 decisions about innovative surgical procedures were made (range 1 to 22 per hospital) in 30 meetings. For 16 innovations NICE guidance was thought to be available and implemented. Further analyses identified that two sets of guidance did not apply (e.g. application of laparoscopic to robotic procedures). 17 innovations were considered at meetings for which NICE guidance was not available. None were referred to NICE. 15 were approved to be undertaken in the hospital, 2 were recommended to seek research ethics approval and 1 was rejected.

Conclusions

Local hospital committees make important recommendations about the introduction of innovative surgical procedures in the NHS. NICE guidance was sometimes difficult to find and interpret and new procedures were generally not referred to NICE. Few were rejected or recommended for research ethics approval. This approach means that local hospitals have large governance responsibilities and there may be inconsistencies across organisations and patient risk. A national strategy is needed to make surgical innovation transparent and safe.
HPB P01 Evaluating quality of life outcomes following Total Pancreatectomy and Islet Autotransplant for Chronic Pancreatitis
Authors: Hughes Daniel , Pandirajan Kamashi , Fox Jennifer , Silva Michael
Published: November 2023

Background

Chronic Pancreatitis (CP) is a debilitating condition that is associated with significant patient morbidity. The disease is characterised by chronic abdominal pain that is recurring and relapsing, which subsequently has a significant impact on the patients’ quality of life. In addition to the stigma associated with the disease, patients often undergo social isolation and are unable to maintain functional status. Total Pancreatectomy and Islet Auto transplant for Chronic Pancreatitis (TPIAT) serves as opportunity to alleviate the pain whilst preserving endocrine function. Our aim was to evaluate whether TPIAT also improved patients quality of life.

Methods

A retrospective review of all patients referred to the TPIAT service in Oxford between 2019 -2022 was performed. Clinical information was recorded regarding patient demographics, aetiology and previous treatment of CP, intraoperative data (islet yield secured) and post operative complication rate. Long term endocrine function, analgesic use and quality of life was formally assessed.

Results

Of the 39 patients referred to the service, 23 (59%) were listed for TPIAT. TPIAT was successfully performed in 21 patients. The median age of this cohort was 22. Hereditary pancreatitis was the most frequent aetiology in 48%. The median length of stay post procedure was 12.5 days. During the last follow up, freestyle libre interrogation highlighted that 79% of patients had blood sugars within the target range. A significant reduction in analgesia use was noted (p=0.001), in addition to a marked reduction in opiate based analgesics (p=0.001). Resolution of pancreatic pain was also significantly apparent in the cohort (p=0.001).

Conclusions

TPIAT for CP serves as an effective treatment strategy as it provides symptomatic relief for patients, reduces long term narcotic use, permits glycaemic control and improves quality of life for patients.
HPB P06 The clinical and molecular landscape of early onset pancreatic cancer
Authors: Dreyer Stephan , Bryce Adam , Jamieson Nigel , Biankin Andrew , Chang David
Published: November 2023

Background

The incidence of Pancreatic ductal adenocarcinoma (PC) is rising in the western world. There is a particularly concerning trend in the rapid increase in incidence of early onset PC (EOPC). The reason for this, and the implications of EOPC is not well understood. The aim of this study was to investigate the clinical outcomes of patients with EOPC and the molecular heterogeneity between EOPC and late onset disease.

Methods

Clinical, pathological and survival outcome data was obtained from 2 large independent prospective cohorts curated by the Australian Pancreatic Genome Initiative (APGI) and the West of Scotland pancreatic unit (Glasgow Royal Infirmary). Patients were categorised into 2 age groups, < 50 and >50 years at time of diagnosis. Clinicopathological and outcome data were compared between groups. Molecular data was obtained from the APGI’s contribution to the International Cancer Genome Consortium, this included transcriptomic, genomic and immunohistochemical data. Molecular subtypes, gene expression signatures, mutational signatures, and tumour microenvironment data was compared between groups.

Results

N=851 patients were identified and n=71 (8%) were < 50 years old. EOPC was associated with earlier recurrence (10.9 vs 14.2 months, P=0.011) and higher incidence of liver recurrence (50% vs 37%, P=0.031). There were no differences in validated clinicopathological variables. Despite an increased proportion of patients with EOPC receiving adjuvant chemotherapy (P=0.020), recurrence was earlier in those that completed > 3 cycles (12.6 vs 16.0 months, P=0.022). There is enrichment of the poor prognostic squamous (basal) subtype (42% vs 28%) in EOPC. There were no differences in the incidence of germline mutations to account for the early onset of disease.

Conclusions

EOPC appears to be increasing in incidence and is associated with earlier recurrence and more aggressive disease pattern. This appears to be associated with resistance to adjuvant chemotherapy and more aggressive, adverse molecular pathology. The onset of early disease cannot be explained by inherited genomic aberrations. Ongoing mutation signature, gene expression and microenvironmental data analysis will be presented upon acceptance of this abstract.
HPB P08 Is Biliary Hyperkinesia a true Pathology? Should cholecystectomy be considered? A prequel towards Pilot study
Authors: Ali Kiren , Shahzad Khan Khurram
Published: November 2023

Background

Biliary Hyperkinesia (BH) is defined as a condition where gallbladder contracts and empties more rapidly than usual causing recurrent biliary colic with no evidence of gallstones on ultrasound or MRCP. Hepatobiliary iminodiacetic acid (HIDA) scan is the investigation of choice and shows gallbladder ejection fraction (EF) of >80% in BH. A recent systematic review and meta-analysis suggested that laparoscopic cholecystectomy (LC) could alleviate the symptoms. Similar results have been highlighted in case reports published about this relatively new gallbladder dysmotility. This study investigates the number of patients with BH on HIDA scan who might qualify for LC.

Methods

This was a 7-year (2015 to 2022) retrospective cohort study of adult patients with biliary pain in the absence of gallstones who underwent HIDA scan. Patient with EF >80% on HIDA scan were included in the study. Electronic case notes were reviewed for demographics, body mass index (BMI), smoking status, liver function tests, duration of symptoms, radiology investigations and endoscopy result including endoscopic ultrasound (EUS).

Results

225 patients had HIDA scan of which 37 (16.4%) patients had BH. Median age was 49 years (IQR 38-62) and 32 (86.4%) were female. Median BMI 28 (IQR 23.3-32.4) and 48.3% were smokers. 5 (13.5%) were referred for pH manometry and gastric emptying studies while 25 (67.5%) have been formally discharged from surgery clinic follow-up. 7 (18.9%) are still waiting for further review.

Only two patients had LC; one 3 years post HIDA when repeat ultrasound eventually showed gall stones and histopathology confirmed chronic cholecystitis. The second patient had sludge seen on EUS and histopathology confirmed chronic cholecystitis.

Conclusions

The hypothesis that overactive emptying of gallbladder represented by a high EF on HIDA scan leads to pain is somewhat convincing. High biliary pressure in a short circuit bounded by gallbladder/cystic duct junction and sphincter of Oddi causes gallbladder mucosal damage and cholecystitis. However, could there be missed stones or sludge is something that still needs to be considered. EUS might be of additional value before diagnosing patient with biliary hyperkinesia. Surgeons should consider LC in patients with BH once other pathologies have been ruled out. Further studies are needed to understand the outcome of cholecystectomy in BH.
HPB P17 Preoperative cardiovascular disease and outcomes ofpancreatoduodenectomy performed for malignancy
Authors: Hall Thomas , Kahar Nurul , Nadeem Nabeegh , Shah Nehal
Published: November 2023

Background

Despite improvements to morbidity and mortality rates in recent decades, pancreatoduodenectomy (PD) remains a high-risk operation. Patients with pre-existing cardiovascular disease (CVD) are known to be at increased risk of perioperative morbidity and mortality. Evidence is lacking on the impact of CVD on long-term outcomes. This study aimed to compare the outcomes of PD patients with preoperative CVD to those without.

Methods

Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Pre-existing CVD included any of the following: hypertension (HTN), atrial fibrillation (AF), other cardiac arrhythmia, ischaemic heart disease (IHD), previous cardiovascular surgery, heart failure, peripheral vascular disease (PVD), previous stroke, previous transient ischaemic attack (TIA), pulmonary HTN, deep vein thrombosis, valve disease, cardiomyopathy, subarachnoid haemorrhage, peri-/myocarditis and myocardial infarction. Several outcomes were compared: length of stay, 30-day readmission, 90-day mortality, unplanned return to theatre rate, and five-year survival.

Results

From 1484 cases, 590 patients (39.8%) had pre-existing CVD. HTN, AF, other cardiac arrhythmia, IHD, previous cardiovascular surgery, heart failure and PVD affected 33.0%, 3.6%, 1.0%, 5.3%, 1.9%, 1.3% and 1.5% of patients, respectively. Remaining pathologies surmounted to <1%. 30-day readmission (10.5% vs 8.1%, p=0.1), 90-day mortality (4.4% vs 3.2%, p=0.3), unplanned return to theatre (5.2% vs 4.8%, p=0.7) and five-year survival (31.2% vs 32.1%, p=0.7) were similar between the patient groups, however, median LoS was significantly longer in those with CVD (14 vs 12 days, p<0.0001). Similar results were obtained when hypertension was not classified as a cardiovascular comorbidity.

Conclusions

In our multicentre study of PD outcomes, patients with a preoperative cardiovascular comorbidity had longer length of stay than those who did not but the other studied outcomes were unaffected.
HPB P31 Delayed discharges in day-case cholecystectomies, a real issue?
Authors: Martinuzzi Michela , Kaur Sukham
Published: November 2023

Background

Elective cholecystectomies are a very common general surgical procedure accounting for approximately 66660 cases a year and costing large amounts of resources to the NHS with significant regional variations in day-case rates1. Initiatives such as Get it Right First Time (GIRFT) aimed at improving the treatment of NHS patients are currently pushing for an increase in day-case rate to at least 75% of all cases and a decrease in regional variations2. The aim of this project was to determine how many patients underwent a day-case elective cholecystectomy, the percentage of delayed discharges and any reasons for the delay.

Methods

Retrospective analysis for which all adult patients admitted for a cholecystectomy at a district general hospital, in six consecutive months were included. For all included patients, ASA score, average age, length of stay, diagnosis and reason for delayed discharge were recorded. Reported complications were also included in the analysis. All data was collected via screening of local electronic health records.

Results

217 patients were included in the analysis. 58% were discharged on the same day; of those not discharged on the same day non-elective operations and planned elective inpatients accounted for 28% and 17% of the total respectively. 75% of all included patients was female and all planned day-cases patients were either ASA1 or 2. Reasons for delayed discharge of planned day-cases included drain placement (18%), social issues (4%), nausea and pain (10%), not meeting discharge criteria such as inability of passing urine (14%) and for 24% of patients no reason was recorded.

Conclusions

Studies have shown that the combination of high ASA and increasing age reduce the likelihood of same day discharge.3 Our study found documentation to be often inaccurate and a potential for better pre-operative selection of patients in order to ensure high levels of safe day-case cholecystectomies.
HPB P32 Ablative techniques in Colorectal Liver Metastases: A Systematic Review and Descriptive Summary of Practice
Authors: Han Ng Wee , Machado Catarina , Rooney Alice , Jones Robert , Rees Jonathan , Pathak Samir
Published: November 2023

Background

In the UK, over 40,000 patients are diagnosed with colorectal cancer annually. Many of these patients develop liver metastases. Although surgical resection is the gold-standard treatment for colorectal liver metastasis (CRLM), some patients are unsuitable for resection. Radiofrequency Ablation (RFA) and Microwave Ablation (MWA) are alternative treatments for CRLM. However, consensus is lacking regarding selection criteria, tumour characteristics, ablation technique delivery, and device settings. This systematic review summarises current evidence regarding selection criteria, treatment indications, and ablation delivery to inform future prospective studies.

Methods

A systematic review was conducted following PRISMA guidelines. Studies assessing RFA and MWA treatment of CRLM were identified in Medline, Embase, Web of Science and the Cochrane database of systematic reviews, from inception until 1st June 2021. Eligible studies included those reporting patient selection, tumour characteristics, treatment delivery, ablation device settings, and ablation outcomes for CRLM. Data extraction and analysis were performed.

Results

Forty-six studies were included (retrospective cohort n=40, prospective cohort n=4, non-randomized comparative studies n=2). Fifty-four inclusion criteria were used across 39 studies and were not stated in 7 studies. Tumours varied in mean number (1-8) and diameter (1.54-4.35cm). Neoadjuvant chemotherapy use (10-100% of patients), ablation delivery approach (Open n=4, laparoscopic n=11, percutaneous n=23, mixed n=2), anaesthetic mode (GA n=17, LA n=9, mixed n=2) and delivering clinician (radiologist n=8, surgeon n=15) all varied. Thirty studies lacked complete ablation device settings. Six studies followed a standardised ablation algorithm and 10 studies had specific settings. Five-year survival ranged from 0-69.7% for ablation.

Conclusions

There is significant heterogeneity in study design, patient selection, and ablation techniques for CRLM. The lack of standardized approaches and inconsistent reporting of methodology and outcomes make it challenging to determine the optimal ablative treatment for CRLM. Future research should focus on clearly defining selection and treatment criteria, as well as treatment delivery to facilitate generalisability. An RCT investigating ablation techniques may be difficult to implement due to a lack of clinician and patient equipoise, however, a high-quality, multi-centre nationwide prospective cohort study to investigate ablation as an alternative to surgery is required for high-risk patients with CRLM.
HPB P33 Evaluating the Disease Burden of Gram-negative Bacteraemia Secondary to Cholelithiasis in a Multi-site District General Hospital
Authors: Dhillon Kieran , Hughes Daniel , Veeramootoo Darmarajah , El-Kafsi Jihene
Published: November 2023

Background

The incidence of symptomatic cholelithiasis continues to rise. We are now observing an increasing number of cases within an elderly, frail, co-morbid patient population. Gram-negative bacteraemia (GNB) secondary to cholelithiasis in this high-risk patient cohort carries a significant morbidity and mortality rate. Reducing GNB rates has been identified as a national target by Public Health England. Our aim is to evaluate the burden of GNB due to cholelithiasis and the management received in a district general hospital in order to inform approaches to reducing the burden of GNB.

Methods

A cross-site audit was conducted across two ‘hot’ district general hospitals serving approximately 1 million people within the same NHS foundation trust. Patients with positive blood cultures for GNB secondary to cholelithiasis were identified. Data was collected regarding patient demographics, survival outcomes, whether definitive treatment for cholelithiasis was performed on the index admission and re-admission rates.

Results

A total of 176 GNB patients from a microbiology database were analysed of which 69 (39%) were identified to have gallstone disease on index admission. Median age of the cohort was 81 years old. Only 10 patients (14%) received a cholecystectomy. Previous gallstone-related admission was found in 23 patients, therefore 23/176 (13%) of GNBs were potentially preventable. Assessment of fitness found 11/176 (6%) were preventable as they were fit for surgery at index non-GNB biliary admission, 4 patients were on a waiting list. Overall, 25 patients were unfit for surgery of which 12 received a drain and 6 were readmitted.

Conclusions

This audit demonstrated a significant proportion of GNB is caused by gallstone disease however a minority of patients are receiving surgery during admission, relinquishing the opportunity to prevent readmission in surgically fit patients. With long waiting times for elective procedures, combatting the burden of GNB requires a shift towards the use of acute cholecystectomy lists. With an increasingly frail population optimal non-operative management is essential to reducing GNB burden, almost half of these patients received a drain which evidence suggests does not reduce recurrence. Greater use of cystic duct stents advised by NICE in this cohort may reduce GNB admissions.
HPB P37 Sustaining and rebuilding a laparoscopic cholecystectomy service in the COVID and post-COVID era
Authors: Dorrian Emmet , Winter Jonathan , Scoffield Julie , Jones Claire
Published: November 2023

Background

In the Belfast Trust (BHSCT), general surgery provision is complex- segregated into emergency and elective care, across multiple sites. The Emergency Surgical Unit (EmSU) provides ‘hot’ laparoscopic cholecystectomy (LC), and aside from a brief pause, continued throughout COVID. Elective LC was offered on another site in conjunction with the HPB service. This site became a COVID centre and surgical wards closed. Few cholecystectomies were performed during 2020/1. In an effort to restore provision, two ambulatory lists were established on the emergency site in December 2021. Subsequently, a regional ‘over-night stay’ unit opened on the original elective site in April 2023.

Methods

Previous BHSCT data demonstrated 300-350 elective LCs are undertaken annually with 66% as day cases. Since COVID, anecdotally significantly less LCs have been performed, and the length of stay (LOS) appeared greater. We performed a retrospective study looking at three time periods for comparison. “Pre-pandemic era” January 2019 to February 2020, “pandemic era” March 2020 to December 2021, and “pandemic recovery” from January 2022 to present. Patients were identified using the local HPB database and the electronic care record was reviewed for each patient. Information was gathered on demographics, day-case rate and LOS, as well as conversion and complication rates.

Results

In all, 827 patients have undergone cholecystectomy since the beginning of 2019. This is significantly less than the projected 1575, based on previous unit volume. Patient demographics are unchanged with mean age of 51.2 years, BMI of 30.27 and M:F ratio of 1:2.3. With the onset of the pandemic, we observed an increase in the average length of stay from 1.22 to 1.77 days with an associated fall in the day-case rate from 63.1% to 35.1%(figure 1). As demonstrated in figure 2, complication rates increased across the board and have been slow to fall in the recovery phase.  

Conclusions

COVID decimated elective surgery globally. Locally, LC provision is an obvious example, with only urgent cases undertaken (76 in 2021 vs 363 in 2019). Unsurprisingly, conversion and complication rates increased.

Despite attempts to reinstate the service, previous volume and outcomes have not been matched for multiple reasons. Increased time to surgery (waiting list >1600pts) means patients present with more severe disease. Ambulatory patients are nursed in EmSU where the environment is not orientated to rapid turnaround surgery. In addition, major losses of experienced nursing staff further impact theatre turnover and added to the challenge of setting up new elective facilities.