bluuebunny/crossref_metadata_2025 huggingface dataset:
BS SO18 - Small bowel intussusception after Roux-en-Y gastric bypass: A case report and review of literature
Authors: Kannan Shanmuga , Haque Afrida , Askari Alan , Adil MdTanveer , Munasinghe Aruna , Al-Taan Omer , Rashid Farhan , Whitelaw Douglas , Jain Vigyan , Jambulingam Periyathambi
Published: November 2024

Background

Small bowel obstruction after RYGB for obesity can occur due to various common causes like internal hernia and adhesions. One of the rare complications of RYGB is retrograde intussusception of jejunum at the common channel. Since it does not present with typical symptoms of small bowel obstruction, it is often challenging to consider it as differential diagnosis at initial presentation. Also, managing the intussusception at non bariatric centres could prove difficult due to location of it in the common channel, which will require understanding of orientation of alimentary and biliary limbs as well as reconstruction after resection of the intussusception.

Method

We collected the details of our patients admission episode from a different centre where she was admitted initially to understand the clinical behaviour of the condition. Also, we conducted a systematic search of literature databases like PubMed, Embase, CINAHL, ProQuest Dissertations & Theses using MeSH terms and keywords Intussusception, Retrograde intussusception, J-J intussusception, Intestinal Obstruction, Small bowel obstruction, Bowel obstruction, Obesity, Morbid obesity, Gastric Bypass, Roux-en-Y gastric bypass, Jejunojejunostomy, Jejuno-jejunostomy, Gastric by-pass, RYGB, Roux-en-Y. Data were extracted on to Excel sheet for analysis.

Results

The search yielded 41 case reports. Patients were operated in most instances except in seven cases where they had multiple episodes. The average age of presentation was 38 mostly in females and few instances being during pregnancy including our patient. Intussusception happened between 5 to 360 months after the initial operation with the average time after the operation being 66 months. Pain was the principal mode of presentation without classical symptoms of bowel obstruction. There were few instances of coffee ground vomiting. CT was the diagnostic modality in almost all cases. Recurrence was invariable when not managed with resection.

Conclusion

Small bowel intussusception after RYGB occurs retrogradely and does not present with classical symptoms and signs of small bowel obstruction. It can be reliably diagnosed with CT abdomen. Of note, medical management and no-resectional surgical management results in recurrence of this condition.
EGS SO08 - How best to time the operative management of acute cholecystitis: Is there a difference in outcomes between hot and smouldering cholecystectomy?
Authors: Marks Bertram , Sow Karmen , Owen Lucy , Haddington-Ahmed Aysha , Carr William
Published: November 2024

Background

Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Acute cholecystitis (AC) is a common emergency presentation in the UK and the 2015 AUGIS guidelines recommend emergency cholecystectomy within 72 hours of admission if the patient is fit. On a practical level this can sometimes be difficult to implement and often patients are discharged to return for an elective procedure (the smouldering gallbladder). We aimed to analyse our practice at a large district general hospital for the management of patients with AC and their post-operative outcomes.

Method

All patients undergoing LC between 1st July 2020 and 30th June 2022 were identified. Patients with an ICD-10 code of K81 (AC) associated with an inpatient stay within a year of their operation were included. Those admitted and operated on during that admission were classified as hot cholecystectomies (HC), whereas those admitted and discharged for an elective procedure were termed smouldering cholecystectomies (SC). Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Statistical analysis was performed using SPSS with Chi-squared tests performed for categorical data and ANOVA for continuous data.

Results

276 patients underwent cholecystectomy for AC with 52.2% elective and 47.8% emergency (91% within 72 hours of admission). HC patients were younger (52.3 vs. 57.5, p<0.01) and less-comorbid (1.67 vs 2.12, p<0.05). The subtotal cholecystectomy rate was comparable between the groups (9.8% vs 16.0%, p=0.131). HC patients had more post-operative drains (38.6% vs 27.1%, p<0.05) and thick-walled gallbladders (92.4% vs 64.6%, p<0.001). Median post-operative length of stay was 1 day for HC and 0 days for SC. No difference was observed for 30-day readmission (4.5% vs 7.6%, p=0.286), morbidity (12.9% vs 11.8%, p=0.786) or mortality (0.8% vs 0.7%, p=0.951).

Conclusion

This study adds to the evidence that emergency cholecystectomy is as safe an option as discharging patients to return for an elective procedure in the future. Although a proportion of those discharged to return for an elective operation will have thin-walled gallbladders, the rate of subtotal cholecystectomy remains similar, if not slightly higher in the elective group (although not reaching statistical significance). Most emergency cholecystectomy patients were discharged the following day, therefore demonstrating that they do not significantly contribute to bed blocking and reduce the burden on already strained elective waiting lists.
EGS SO23 - The undifferentiated general surgical take over 10 years: Emergency operating
Authors: Hale Emily , Dean Lydia , Bowling Kirk
Published: November 2024

Background

The aim of this study is to further understand the specific pressures on the department’s operating theatres and capacity, and to identify areas in which we could adapt to facilitate these demands, by reviewing the undifferentiated general surgical admissions in a District General Hospital in July 2013 and July 2023.

Method

All patients seen by the emergency general surgical team in July 2013 and July 2023 were identified retrospectively. Data was gathered using electronic notes, to analyse admissions and surgeries within 30 days. Patients were excluded if there was insufficient information available.

Results

26% (n=102/395) of all patients treated by emergency general surgical teams in July 2013 had surgery within 30 days. This proportion reduced to 23% (134/594) in July 2023, however overall volume has increased by 31%. The proportion of procedures performed on the day of admission has decreased from 10% to 7%. 3% of procedures were performed under local anaesthetic both in 2013 and 2023. Wait from admission to surgery has decreased from 2.84 days (+/-0.6, p=0.02) in 2013, to 1.9 days in 2023 (+/-0.83, p=0.02).

Conclusion

Although volume of procedures within the same 31-day period has increased throughout the 10 years, the proportion of patients that proceed to intervention has reduced marginally. This is reflected in the increasingly busy emergency operating lists throughout the country, with little change in resources to account for increasing volume. The rising proportion of patients managed conservatively may represent improving medical management of conditions, or more pragmatic management of frail patients.
EGS SO32 - Management of Spontaneous Oesophageal Perforations in the era of Endo-Vacuum Therapy- Preliminary Results of a Single-Institution Study
Authors: Baili Efstratia , Ibrahim Ahmed , Alasmar Mohammad , Farooq Naheed , Powell Arfon , Alkhaffaf Bilal
Published: November 2024

Background

Spontaneous Oesophageal Perforation (SOP) is a rare gastro-intestinal surgical emergency with devastating morbidity and mortality. Given the rarity of the entity, there is no up-to-date evidence on outcomes in the context of centralized esophagogastric services neither consensus guidelines nor standardized treatment algorithms on how these should be optimally managed. Endoscopic Vacuum Therapy (EVT) has emerged as safe and effective option particularly in cases where major invasive surgery would otherwise be deferred. Herein, we sought to explore the effectiveness, patient benefit and related morbidity/mortality by exploring the strategy outcomes in SOPs prior to and during periods where EVT was available.

Method

A single-centre retrospective cohort study incorporating all consecutive patients (N=72) presented or transferred to our tertiary oesophagogastric unit for SOP management between 01/01/2009-31/12/2023 was undertaken. Patients with anastomotic leak post-surgery or perforation secondary to malignancy, iatrogenic, traumatic or food bolus were excluded. Primary study-outcomes were treatment type including non-operative, EVT after 01/01/2018 or other endoscopic therapy, surgical operation including laparotomy, thoracotomy, primary defect repair or over a T-tube, disconnection with oesophagostomy, stenting or other interventional radiology procedures and their rate of success or failure. Secondary outcomes were length of stay, 90-day complications requiring re-intervention or re-admission, 30-, 90-day, 1-year mortality.

Results

In 2009-2017 pre-EVT period, 25/72 patients were managed a) 18/25 surgically with thoracotomy and T-tube, b) non-surgical 7/25, four were palliated. 30-day, 90-day mortality were 4/25 and 2/25, 90-day morbidity Clavien-Dindo >IIIa 14/25 (56%), 90-day reintervention 8/25 (32%), median LOS 27 days. In 2018-2023 EVT period , 47/72 patients were treated with a) laparotomy, left thoracotomy, defect repair over t-tube, chest drainage in 18/47, b) non-surgical 15/47, c) endoscopy 6/47, d) EVT in 14/47. 30-day mortality was 6/47, 90-day mortality 2/47, 90-day morbidity Clavien-Dindo >IIIa 32/47 (68%), 90-day reintervention 26/47 (55.3%), median LOS 34 days. 1-year mortality was 5/25 and 3/47 respectively.

Conclusion

EVT therapy appears to be a feasible additional treatment modality in the management of spontaneous oesophageal perforations. Optimal patient selection, therapeutic endoscopic expertise, knowledge of the technique, multidisciplinary approach and team collaboration are essentials for favourable outcomes. Of note, management of oesophageal perforations in a dedicated UGI centre is directly related to patient outcomes and is recommended as soon as such a diagnosis is confirmed.
EGS SO35 - Emergency laparotomies in the elderly: A patient perspective
Authors: Davis Heather , Hale Emily , Sert Sena , Bowling Kirk
Published: November 2024

Background

Emergency laparotomy is known to convey worse morbidity and mortality for elderly patients. Despite a growing elderly population, there is a limited understanding of the patient experience in emergency laparotomy. This study aims to assess patient satisfaction following emergency laparotomy.

Method

Patients were identified from the National Emergency Laparotomy Audit (NELA) database, who were aged 80 and above, and underwent surgery between: January 2020 and August 2023 at Torbay Hospital. Of the patients who survived to discharge, a telephone-based interview was undertaken in January 2024. Exclusion criteria included: confusion, severe illness and relook laparotomy. Data was collected on functional status and satisfaction with the procedure. Patients were also asked what they wished they known prior to the operation. Post-operative outcomes were assessed in a separate study.

Results

132 cases were undertaken in this period. 72 cases met inclusion criteria. We achieved a 54% response rate. 59% of respondents were living independently post operatively and had no functional decline. 92% of respondents were happy to have had the operation and if given the opportunity again would still have had the procedure. Patients were overall very happy with the information offered prior to the procedure, 8% felt they had no alternative option. One patient was not satisfied with the follow up received.

Conclusion

Although emergency laparotomy in the elderly is high risk, our data demonstrate excellent patient satisfaction. This study provides a better understanding of what is important to patients; this should be considered in the consent process and communication.
OGC SO03 - Impact of recent European consensus guidelines on Oligometastic Disease (OMD) and potential case load of Oesophagogastric cancer resections
Authors: Shenoy Sachin , Sivarajan Sri , Gissmondi Martha , Sreedharan Loveena , Lewis Micheal , Penney Nicholas , Kumar Prof Bhaskar
Published: November 2024

Background

To evaluate the impact of recently devised oligometastatic disease (OMD) criteria as per the European consensus guidelines on the eligibility of Oesophagogastric (OG) cancer patients for curative treatment.

Method

A retrospective analysis was conducted on OG cancer cases discussed at multidisciplinary team (MDT) meetings at a tertiary university hospital from January 2018 to December 2023.

Inclusion criteria included T2-T4a adenocarcinomas, T2-T4b squamous cell carcinomas, small cell carcinoma and adeno-squamous carcinomas that were classified as M1 disease.

Exclusion criteria were T4b adenocarcinomas, M1 peritoneal disease, non-adeno/ squamous carcinoma histology, M1 peritoneal cytology, and head and neck squamous cell carcinomas proximal to the thoracic inlet.

Data on patient demographics, T stage, histology, and metastatic sites were analysed to identify those meeting the oligometastatic disease criteria.

Results

483 of 696 were diagnosed as M1 disease. OMD was found in 59 cases (12.2%), with a median age of 72 years (43 males, 16 females). T stage distribution: 3 T2, 36 T3, 20 T4. Histology: 39 adenocarcinomas, 19 squamous cell carcinomas, 1 small cell carcinoma. Metastatic sites: non-regional lymph nodes (77.9%), liver (13.6%), lung (5.1%), bone (1.7%), adrenal (1.7%)

Location of Lymph Node Involvement: 1Para-aortic11 (23.9%)2Right supra-clavicular7 (15.2%)3Porto-caval6 (13.0%)4Retro-crural5 (10.9%)5Upper mediastinal5 (10.9%)6Left Supraclavicular5 (10.9%)7Coeliac4 (8.6%)8SMA3 (6.6%)

Conclusion

Our data would suggest that 12.2% of patients discussed in the MDT may potentially be candidates for a curative intent treatment pathway. Although the long-term outcomes remain unclear, this approach may define a subgroup of patients who may benefit from curative intent treatment with the highest site being para-aortic nodes.
OGC SO13 - Recurrence Patterns after Minimally Invasive vs. Left Thoracoabdominal Oesophagectomy for distal oesophageal and junctional adenocarcinomas
Authors: Salem Riadh , Dassanayake Ashan , Gillies Richard , Owen Richard , Markar Sheraz , Marshall Bob , Maynard Nick , Sgromo Bruno
Published: November 2024

Background

Oesophageal cancer is a leading cause of cancer-related death worldwide, with oesophagec-tomy being the primary treatment for curable disease. This study compares loco-regional and distal disease recurrence patterns between minimally invasive oesophagectomy (MIO) and left thoracoabdominal oesophagectomy (LTAO) using a matched dataset. The definition of loco-regional recurrence remains unclear in the literature. In this study, loco-regional recur-rence is categorised as recurrence in the oesophageal bed, anastomosis, or local nodes in the mediastinum and upper abdomen.

Method

Patients from 2014 to 2021 were identified and followed until 31/12/2023. Data on MIOs and LTAO were collected from a prospectively maintained database. Gastroesophageal junction and distal oesophagus adenocarcinomas were included, and all received neoadjuvant chemotherapy. Out of 302 eligible patients, 104 were successfully matched. The primary outcome was overall cancer recurrence.

Categorical variables were compared using chi-square tests, and non-parametric contin-uous variables with Mann-Whitney U tests. Propensity score matching, accounted for baseline differences. Logistic regression generated propensity scores for age, gender, and tumour stage. Operative approach was the dependant variable. The groups were then selected using ‘nearest neighbour’ matching.

Results

The study compared 52 cases each of LTAO and MIO. Postoperative complications were similar, LTAO (58%) and MIO (52%) P=0.554. The R0 resection rate was higher in LTAO (90%) compared to MIO (81%) P=0.163. Recurrence was significantly higher in LTAO (42%) than MIO (23%) P=0.037. Local recurrence rates were 15% for LTAO and 8% for MIO P=0.22. Distant recurrence was 35% for LTAO and 21% for MIO P=0.111. Notably, peritoneal recurrence was significantly higher in LTAO (12%) P=0.012. There was no difference in median time to recurrence. Mortality rate was similar: 38% for LTAO and 35% for MIO P=0.684.

Conclusion

The study found that while postoperative complications and mortality rates were similar between LTAO and MIO, LTAO had a significantly higher overall recurrence rate and notably higher peritoneal recurrence. There was no significant difference in median time to recurrence between the two groups. These findings suggest that MIO may be associated with better long-term outcomes in terms of recurrence.
OGC SO25 - Tumour Regression Grade (TRG) and Completeness of Resection in patients under esophagectomy for oesophageal Cancer
Authors: Bhatti Khalid , Vaz Osborne , Ward Jeremy , Pursnani Kish , Turner Paul , Sarantitis Ioannis , Nandi Sumit , Ibison Frances , Nair Beena , Shetty Vinutha Daya
Published: November 2024

Background

Oesophageal cancer, including squamous cell carcinoma (SCC) and adenocarcinoma, is challenging due to its aggressive nature and delayed presentation. Neoadjuvant chemotherapy aims to downstage the tumour thus aids in surgery and improves patient outcomes. Complete resection with tumour free resection margins is crucial for cure and survival. Understanding the relationship between tumour regression grade (TRG) and completeness of resection helps improve outcomes in patients with oesophageal cancer.

Method

This retrospective study was conducted over a period of 4 years (2019-2023). It included all patients over 18 years of age who underwent oesophagectomy for either squamous cell carcinoma (SCC) or adenocarcinoma following neoadjuvant chemotherapy. Tumour Regression Grade (TRG) was defined by the histological report while R1 resection was defined as any margin less than 1 mm. Statistical analysis was performed to evaluate the incidence of complete and incomplete resections across the various TRG groups.

Results

Study included 214 patients (178 males, 36 females) with a median age of 67 (31-82) years. Of the 214 patients, 201 (93.9%) had adenocarcinoma and 13 (6.1%) had SCC. Complete resection was achieved in 136 patients (63.6%), while 78 (36.4 %) had incomplete resections. TRG distribution in the complete resection group was-TRG 1 (97.6 %), TRG 2 (76.5 %), TRG 3 (67.2 %), TRG 4 (56.1 %), and TRG 5 (31.9 %). The Chi-Square test indicated significant associations between TRG and resection completeness (Chi-Square = 44.229, p < .001; Likelihood Ratio = 51.804, p < .001; Fisher's Exact Test p < .001).

Conclusion

The study demonstrates a significant correlation between higher TRG scores and incomplete resections in esophagectomy patients’ post-neoadjuvant chemotherapy. We conclude TRG is an important prognostic indicator for surgical outcomes in oesophageal cancer.
OGC SO26 - Double tract reconstruction post total gastrectomy enables duodenal surveillance in familial polyposis: Case report
Authors: White Michael , Chevallay Mickael , McDonnell Declan , Underwood Tim
Published: November 2024

Background

Familial polyposis syndromes such as Juvenille polyposis syndrome (JPS) and Familial adenomatous polyposis (FAP) are associated with ∼21% and ∼11% lifetime risk of foregut carcinoma respectively. In patients effected, routine oesophago-gastro-duodenoscopy (OGD) is recommended every 1-3 years, in JPS from 15 years old and in FAP from 25 years old. In patients with malignant transformation traditional resection with Roux-en-Y reconstruction inhibits future duodenoscopy.

Method

Between April and July 2024 two patients presented requiring total gastrostomy with familial polyposis syndromes. In both cases laparoscopic total gastrectomy with double tract reconstruction was decided upon to enable future duodenal surveillance.

Results

Case 1: 45 year old female with JPS (germline SMAD 4 mutation). Surveillance detected a massive circumferential proximal gastric polyp comprising ∼30% of total gastric mucosa, too large for endoscopic therapy. Biopsies showed JPS polyps. Patient had no early complications following laparoscopic total gastrectomy and a post operative barium swallow showed clear passage of contrast down the double tract.

Case 2: 61 year old male with FAP (germline APC mutation). Surveillance detected innumerable fundic gland polyps with histology demonstrating multifocal high grade dysplasia. Previous subtotal colectomy Planned for laparoscopic total gastrectomy with double tract reconstruction in July 2024

Conclusion

Roux-en-Y reconstruction is the most common reconstruction following total gastrectomy. However, in patients with familial polyposis syndromes ongoing lifelong duodenal surveillance is critical. In such patients double-tract reconstruction instead of Roux-en-Y may be preferable allowing future duodenoscopy and acceptable remnant foregut function.
OGC SO34 - Textbook Outcome in Gastric Cancer Elective Surgery: A multicentre analysis
Authors: Marques Cláudia , Dionísio Daniela Venâncio , Costa Paulo , Abouelazayem Mohamed , Wong Geoffrey , Vish Y K S , Boddy Alex , Donohoe Claire , Singhal Rishi , Mahawar Kamal , Study H O L D
Published: November 2024

Background

Textbook outcome (TO) is a composite measure of surgical outcomes that, when collectively achieved, depict the optimal result for the patient. Multidimensional parameters, like TO offer a in depth picture of hospital performance, by combining multiple indicators. While an increasing number of studies are evaluating TO in cancer, its application for gastric cancer is still a recent advance. Since surgical reality differs worldwide, a common language is essential when setting outcome goals.

This study aims to assess TO accomplishment in several hospital typologies that offer curative-intent resections for gastric cancer.

Method

A prospective observational multi-institutional audit and 90 day follow-up included data from 138 institutions, in 47 countries. This is a preliminary analysis with focus on TO. Adult patients who underwent elective gastric cancer resection with curative intent, between April 1st and September 30th, 2022, were included.

Textbook Outcome (TO) was achieved when all the following seven criteria were met: complete resection (R0), more than 15 lymph nodes sampled, discharge before 21 days, no mortality, no severe morbidity (Clavien–Dindo over 2), no reintervention and no readmission within 90 days post-operative.

Results

A total of 380 collaborators submitted data on 1538 patients. The mean age was 64.2 years and 58.5% were males. A total of 734 (48%) from the included 1538 patients, achieved TO. “No reintervention in 90 days” was registered in 92% of patients. “No morbidity in 90 days” was observed in 71%. “More than 15 lymph nodes sampled" was achieved in only 79%. The 90-day morbidity and mortality rates were 38.2% (n=587) and 2.9% (n=45), respectively.

Conclusion

This study demonstrates that achieving Textbook Outcome in gastric cancer resection is seldom attainable. A significant variability across the different outcome parameters within the participating centres was expected.  

The high rates of mortality-free and reintervention-free outcomes express an effective postoperative care. The lower rates of adequate lymph node sampling and morbidity-free outcomes indicate areas for improvement.  

Further research should focus on standardizing protocols and improving specific surgical practices to enhance overall TO rates in gastric cancer patients, among the hospital typologies and geographic locations, included in this study.
BN SO08 - A Comparison of outcomes following Laparoscopic Cholecystectomies before and after COVID-19
Authors: Nicholas Felix , Viswanathan Naveen , Escofet Xavier
Published: November 2024

Background

The COVID-19 pandemic led to the suspension of elective surgeries between March 2020 and March 2021 in the NHS and large parts of the world. In Prince Charles Hospital, elective services were phased in from April 2021 and elective laparoscopic cholecystectomies resumed in June 2021. There is an almost universal perception among surgeons that the cholecystectomies after covid disruption, have become more technically demanding, resulting in longer operative times and poorer outcomes. This study aims to quantify the differences in indications, CLOC score, Parkland grades, and outcomes, following elective cholecystectomy, one year before and after COVID

Method

Laparoscopic Cholecystectomies performed on elective lists between January 2019 and December 2019 by two UGI surgeons were included in the pre-COVID group. Cholecystectomies performed between September 2021 and August 2022 by the same UGI surgeons were included in the post-COVID group. Cholecystectomies on the CEPOD list and procedures which included CBD exploration or choledochoscopies were excluded. Demographics, ASA, indications, waiting times, operative times, CLOC and Parkland scores were collected. Outcome measures were complications, drains, hospital stay and proportion of subtotal colectomy, day case surgeries, and conversions to open. An online calculator for social science statistics was used to analyze data.

Results

The pre-covid(n=92) and post-covid(n=98) groups were comparable in age(P=.37), gender(P=.06) and ASA(P= .057). Pre Covid, lower Proportion of patients underwent cholecystectomy for previous cholecystitis(precovid 13.04%, post-covid 35.7%)(P<.001). Pre Covid Cholecystectomies were shorter(pre-covid 74 minutes, post-covid 85 minutes, P=.018). The mean CLOC score and Parkland grade in precovid group (CLOC= 4.03, Parkland 1.8) were less than in the postcovid group(mean CLOC=5.41, mean Parkland 2.5)( P<.001, P=.006). Apart from the Subtotal Cholecystectomy rate (5.4% pre-covid vs 12.2 postcovid, P=-04) and drains (P=.02), there were no significant differences in outcome measures.

Conclusion

This study demonstrares that the COVID disruption resulted in more challenging procedures, indicated by the increase in CLOC score, Parkland grade, and longer operating times. This is a reflection of a much larger proportion of surgeries being performed for previous cholecystitis. There are however no significant differences in outcome, except the higher rates of subtotal cholecystectomy. This suggests that the skills and techniques have compensated for higher difficulty levels. Data does show an approximately 15% difference between the groups in all other outcome measures which however does not reach statistical significance. A larger sample is needed to clarify this.
BN SO21 - Factors influencing subtotal cholecystectomy
Authors: Marks Bertram , Sow Karmen , Owen Lucy , Haddington-Ahmed Aysha , Courtney Michael
Published: November 2024

Background

Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Sub-total cholecystectomy (SC) has become increasingly utilised as a safe alternative to conversion to open when unable to visualise the critical view of safety. This avoids the morbidity of an open operation whilst minimising the risk of iatrogenic injury to the common bile duct. Male sex, increasing age, previous acute cholecystitis and ERCP have previously been identified as independent risk factors for SC. We aim to identify factors that increased the likelihood of SC within our cohort and the effect of SC on post-operative morbidity.

Method

All patients who had LC as either an elective or emergency procedure between 1st July 2020 and 30th June 2022 were identified and included in this study. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Any post-operative complication was noted and graded according to the Clavien-Dindo classification. Statistical analysis was performed using SPSS with ANOVA analysis being performed for continuous data. Odds ratios were calculated with a 95% confidence interval. Statistical significance was taken as a p value < 0.05.

Results

974 patients underwent LC with 4.8% having SC. Factors associated with increased risk of SC included: previous acute cholecystitis (OR 9.37 (4.69-18.70), increased age (mean = 58.7 vs 50.9), higher Charlson co-morbidity index (mean = 2.60 vs 1.43) male sex (OR 2.49 (1.38-4.48), emergency operation (OR 2.30 (1.23-4.30), Diabetes Mellitus (OR 2.58 (1.23-5.36); and previous ERCP (OR 2.62 (1.13-6.11). 30-day morbidity was higher for SC (25.5% vs 8.1%) with major complication (Clavien-Dindo > 2) being significantly more frequent (OR 6.64(2.53-17.4). Median post-operative length of stay was 2 days for SC and 0 days for LC.

Conclusion

Although regarded as a safe option in difficult cholecystectomy, our study shows that there is significant morbidity associated with subtotal cholecystectomy. However, the majority of patients only require a short hospital stay post-operatively. Multiple risk factors were identified for SC with previous acute cholecystitis being the most strongly associated with SC. Diabetes was identified as an independent risk factor alongside higher Charlson co-morbidity index as a generic marker of co-morbidity. Interestingly, CBD diameter > 8mm on pre-operative imaging was not shown to increase risk of SC.
BN SO27 - Articulative Minimally Invasive Surgery and Placement of Anti-reflux Magnetic Surgical Appliance (LINX)
Authors: Pua Qiao Ying , Loh Danielle , Kwan Yi Xin , Viswanath Y K S
Published: November 2024

Background

Gastro-oesophageal reflux disease (GORD) is a condition of prolonged retrograde flow of gastric contents into the oesophagus or structures beyond, causing symptoms such as heartburn and regurgitation.1 Laparoscopic Nissen Fundoplication (LNF) has been the surgical gold standard, however its side effects and technical challenges has limited its use to 1% of the GERD population.2 The use of a magnetic surgical appliance (LINX) has recently emerged as a promising treatment in overcoming the limitations of conventional LNF.3 Literature has shown patients aged less than 45 with satisfactory mean contraction amplitude (MAP) of 30mmHg and typical symptoms have favourable outcomes with LINX.3

Method

This is a case of a 35-year-old patient presenting with typical reflux symptoms, with satisfactory MAP and high DeMeester score, patulous gastro-oesophageal junction and no hiatus hernia endoscopically. Steps for LINX placement are described in the video and we demonstrate the use of ArtiSential, an articulating laparoscopic instrument that provides better range of motion and angulation comparable to that of a robotic instrument.

Results

Using a magnetic surgical appliance (LINX) is superior to LNF through preservation of physiological belching and vomiting, reducing surgical time and duration of hospital stay while also scoring highly on quality of life and patient satisfaction.4

Conclusion

We would recommend considering the placement of a LINX device in suitable patients as it provides good outcomes on par with LNF and to consider the use of an articulating instrument (ArtiSential) as it provides the surgeon better control and ease in placing a small device laparoscopically.
BN SO31 - Pedicle First; a Paved Laparoscopic Approach for Huge Splenomegaly
Authors: Shaaban Mohamed , Farag Mohamed
Published: November 2024

Background

Since its introduction for the first time by Delaitre et al1 in 1991, laparoscopic splenectomy (LS) has become the minimal invasive approach of choice for the management of the hematological splenic disorders2. Many agreed benefits have been achieved with this approach regarding the hospital stay, blood loss, duration of recovery, aesthetic results and quality of life; however, massive spleens remain a real technical challenge in front of achieving those benefits. The complex and non-typical variable configurations of the vascular system for the pancreatic body and tail which come from the splenic artery represents another faced point of anatomical complications3.

Method

From March 2020 to February 2024, a prospective study has included 30 patients presented with benign hematological disorders and massive splenomegaly (more than 20 cm longitudinal axis) who underwent laparoscopic splenectomy in our institution. Detailed data regarding their demographics, splenic size, operative time, blood loss, conversion rate, postoperative serum amylase and hospital stay were collected. Standardized anterior approach operative steps were adopted by the same surgeon for all patients with early control of the arterial system of the splenic circulation before mobilization (short gastric vessels and splenic artery 2 to 4 cm away from hilum).

Results

Thirty patients presented with huge splenomegaly have underwent laparoscopic splenectomy with a conversion rate of 6.6% (2 patients due to extensive perisplenic adhesions). The mean longitudinal splenic dimension was 24 ± 1.5 cm (range from 20 to 27 cm), mean operative time was 110 ± 16 minutes, mean operative blood loss was 160 ± 20 ml, mean hospital stay was 4 ± 1.5 days, postoperative rate of hyperamylasemia in 20% (asymptomatic 6 patients with no operative evidence of pancreatic injury), respiratory complications in 16.6 % (5 patients), and reactive thrombocytosis in 6.6% (2 patients).

Conclusion

Early laparoscopic control of the arterial system away from the splenic hilum can enable us to lessen the conversion rate for massive splenomegaly patients and achieve successfully the benefits of laparoscopy for those patients on the expense of the elevated postoperative hyperamylasemia rate.
BN SO35 - A Novel Ambulatory Pathway in the Management of Acute Pancreatitis
Authors: Gopalan Vignesh , Fox Benjamin , Baker Daniel , Walters Mary , Blencowe Natalie , Peckham-Cooper Adam , Pathak Samir , Hollyman Marianne
Published: November 2024

Background

Acute Pancreatitis (AP) accounts for 20000 admissions per year, resulting in an average hospital stay of 5 days. Over 90% of patient have mild or moderate disease severity. Validated risk stratification tools such as the Harmless Acute Pancreatitis (HAP) score utilised alongside biochemical markers and clinical acumen can predict up to 97% of patients with a mild disease course.

A pathway was introduced at two NHS centres to enable diagnosis and ambulatory management of patients with predicted mild AP with the aim of improving patient experience by preventing unnecessary admission, reducing pressure on surgical departments and providing safe outpatient management.

Method

The study took place at two sites: a district general hospital (DGH) and a tertiary referral centre. Pathway development occurred in parallel to pilot. Ambulation was defined as no overnight stay in a hospital bed. An initial retrospective review of all AP admissions was undertaken to understand current burden of disease and severity in our centres.

Suitable patients were identified prospectively and data (demographics, biochemical markers, modified HAP score, severity of disease, complications, re-admission rate, surgical or endoscopic intervention) were collected for up to 30 days after discharge. AP ‘proforma’ were created to understand surgeons decision-making surrounding ambulation versus admission.

Results

Between November 2023 and May 2024, 99 patients with AP presented to the DGH surgical unit. Causes of AP included gallstones (n=55), idiopathic (n=21), alcohol (n=17), and post-ERCP (n=2). 38 patients (38%) were ambulated, with 23/38 (61%) returning for planned review within 72 hours.

There were no mortalities in the ambulatory group. Three (7%) ambulated patients were re-admitted within 30 days for pain control (n=2) and post-cholecystectomy complications (n=1).

Reasons for non-ambulation included: pain (n=30), inpatient cholecystectomy (n=4), poor oral intake (n=4), social reasons (n=3).

In 4-week tertiary data collection, 5/17 (29%) eligible patients were ambulated, with 1 (20%) re-admission.

Conclusion

Pilot of a novel pathway to identify and ambulate patients with a predicted mild course of AP has been successful across two NHS centres. Use of validated risk scores alongside biochemical markers and clinical acumen produces a safe, sustainable and effective pathway that reduces burden on inpatient surgical resources.

It is safe and feasible to ambulate patients with AP whilst undertaking diagnostic imaging, managing symptoms, facilitating expedited cholecystectomy and arranging specialist review in the outpatient setting.

Further work is required with stakeholders to refine the pathway and replicate these results in other surgical units.
BN SO37 - Upper GI surgical training in the UK: Are there enough training opportunities? 10-year trends in Benign Upper GI index procedures and the impact of COVID-19
Authors: Brown Oliver D , Aroori Somaiah
Published: November 2024

Background

Surgical training was adversely impacted during the COVID pandemic, with reports of reduced logbook numbers and challenges in meeting training competencies. Despite a national elective care recovery plan, and interventions aimed at maintaining training opportunities, waiting list expansion has continued and has particularly impacted benign procedures. Upper GI trainees are all required to achieve “Level 4” (independent) competence in Cholecystectomy and Antireflux surgery, however there are anecdotally. fewer opportunities in the post-COVID era to train in these procedures. This study aimed to evaluate trends in these index procedures and to compare the pre- and post- COVID eras.

Method

The annual Admitted Patient Care (APC) publications draw on Hospital Episode Statistics and summarise activity for each financial year by OPCS4 codes. Codes pertaining to cholecystectomy and antireflux surgery (the “Benign Upper GI” competences on the Joint Committee of Surgical Training New Curriculum Checklist) were screened for inclusion. Data were extracted from APC publications between 2013 and 2023. These data were summarised in a Microsoft Excel Spreadsheet, categorised by index procedure and divided into pre-covid (2013-2019) and post-covid (2019-2023). Trends were evaluated using a Mann-Kendal Non-Seasonal Trend Test. Comparisons were undertaken using a two tailed unpaired t-test.

Results

Between 2013 and 2023 there was a statistically significant negative annual trend in the number of cholecystectomies from 75934 to 68182 (p=0.02), with a minimum of 47803 in the 2020-2021 financial year and a non-significant positive trend in the subsequent years. There were significantly fewer cholecystectomies in the 4 years following COVID (mean 77357 vs 63882, p=0.015). Antireflux procedures also underwent a significant negative trend from 5467 to 4745 (p=0.02), with a minimum of 2565 in the 2020-2021 financial year and a non-significant positive trend in subsequent years. Mean post-COVID antireflux procedures were also significantly lower (5548 vs 4256, p=0.03).

Conclusion

The procedures required for training in Benign Upper GI surgery in the UK are occurring with lower frequency than before the COVID pandemic. Whilst this may reflect ongoing operational pressures, or changes in clinical practice, this evidence suggests that training opportunities are now less frequent. This highlights the importance of focussed training and an awareness of training needs amongst both trainees and their mentors.
BN SO49 - An early experience in robotic Upper GI surgery at a busy District General Hospital
Authors: Patel Maitreyi , Mukherjee Dipankar , Mukherjee Samrat
Published: November 2024

Background

Robotic surgery is being adopted in performing Upper GI surgery due to the added advantage of precision and safety. Current literature suggests that robotic surgery may be associated with improved patient outcomes, such as blood loss, length of stay and perioperative complications, with majority of evidence stemming from colorectal, urological or thoracic surgical domains. Our UGI unit started robotic surgery in November 2021, initially one surgeon trained, and from June 2022, a second consultant surgeon began robotic surgery. This study describes the early outcomes of robotic Upper GI surgery at our UGI surgery Unit in a busy District General Hospital.

Method

We retrospectively assessed data of patients undergoing Robotic UGI surgery from a prospectively maintained database. Patient demographics, surgical procedure and duration of surgery was recorded. Conversion rates, post-operative complications and length of stay were recorded.

Results

Between November 2021 and January 2024, 125patients underwent robotic UGI surgery at our Hospital. The surgeries included cholecystectomy (n=80), Anti-reflux surgery (n=22), Hellers cardiomyotomy (n=4), Gastrectomy (n=6) and oesophagectomy (n=1). The median length of stay was 2 days. Morbidity as per Clavein-Dindo classification 3 and 4 was 3%. There were no mortalities.

Conclusion

Our preliminary experience suggests that robotic surgery is feasible and safe. It has low complication rate and reduced critical care stay. A structured training of surgeons ensures a safe introduction of robotic services.
BN SO56 - Post-ERCP clearance of bile duct stones: Should the gallbladder be left in-situ?
Authors: Lin Cindy Wong Siaw , Tanner Nicola
Published: November 2024

Background

Laparoscopic cholecystectomy (LC) has become the gold standard treatment for patients with cholelithiasis and co-existing common bile duct stones (CBSD) with the ultimate goal to prevent further biliary complications. Despite the procurement of ERCP and LC skills, there still remain a significant proportion of patients who are treated non-operatively. There has been debate on the safety of a ‘watch-and-wait’ policy post ERCP for clearance of CBDS alone. The objective of our study was to review our current practice and compare the outcomes of expectant management (EM) versus LC with an aim to evaluate the necessity of LC after ERCP.

Method

A retrospective review of patients who underwent ERCP for choledocholithiasis from 1st January 2017 to 31st December 2019 was performed. Exclusion criteria applied to patients with previous cholecystectomy, absence of CBDS, gallbladder/pancreatic malignancy, biliary stricture and patients lost to follow-up. Patient characteristics, details of ERCP, initial plan for EM or LC, details of LC and further changes in treatment plan were extracted from the prospectively maintained database of a single institution. Age 70 years is used as cut-off to define elderly group. Primary outcomes measured were biliary-related morbidity and mortality. Secondary outcomes included all-cause mortality, operation-related morbidity and mortality.

Results

265 patients were identified, with 136 patients primarily planned for EM and 129 patients initially booked for LC. The median age of patients in the EM group was greater than LC group (80 vs 62 years). 20.6% patients in the EM group re-presented with biliary events compared to 3.9% in the LC group. The median time from first ERCP to recurrence of biliary events in the EM group was 14 months. There was no significant correlation between age and complications from LC. However, 51.4% of our EM group died during follow up with a median survival of 29.5 months.

Conclusion

Prophylactic cholecystectomy should be performed for patients with concomitant cholelithiasis and choledocholithiasis. A conservative approach should be reserved for the elderly population who are not ideal surgical candidates. A follow-up of up to 2 years is recommended for patients who opt for a ‘watch-and-wait’ approach. Early LC is preferrable due to the risk of recurrence of biliary events and the higher risks of surgery if patients require emergency surgery. Further study is warranted to determine the optimal timing for LC. Patients should be informed about the potential recurrence of symptoms if the waiting time to surgery is longer than expected.
BN SO57 - Transversus Abdominis Plane (TAP) Block in Laparoscopic and Robot-Assisted Cholecystectomy: Is it worth the effort?
Authors: Sira Sukhbir , Suresh Reena , Choudhry Mariam , Tongo Folashade , Koo Huifen , Simoadefreitas Sabrina , Mukherjee Samrat
Published: November 2024

Background

Minimal access cholecystectomy is a common procedure undertaken worldwide. These are usually performed on an ambulatory basis and given the short timeline, strategies to optimize pain control and reduce nausea or vomiting are key factors to facilitate early hospital discharge. There has been studies showing that both TAP block and wound infiltration deliver superior pain relief after laparoscopic cholecystectomy, but TAP blocks are not used routinely after cholecystectomy in the U.K.

This study aims to assess the efficacy of post-operative subcostal TAP block in laparoscopic and robot-assisted cholecystectomy in reducing post-operative opioid requirements and facilitating same day discharge.

Method

A retrospective cohort analysis was performed at a single centre (January 2022 – July 2023). Patients undergoing laparoscopic or robot assisted cholecystectomy under a single surgeon who performs cholecystectomy with additional use of postoperative TAP block were included. The primary outcome of post-operative opioid requirements was assessed. Secondary outcomes included length of post-operative stay and individual morphine/fentanyl requirements.

Results

Among 87 patients, 22(25.3%) underwent TAP block and 65(74.7%) had local anaesthetic infiltration of the port sites. Of the two cohorts, there were no significant differences in the age, M:F ratio or ASA grade. There were more obese patients (BMI > 30kg/m2) in the TAP block cohort (63.6% vs 47.7%; p= 0.012).

Of the patients in the TAP block, 88.2% were discharged the same day. 95.5% of these patients had no post-operative morphine or fentanyl requirements.The difference in outcomes were not statistically significant. There were no post-procedural complications from use of the TAP block in any patient.

Conclusion

These results demonstrate that use of TAP block can provide a safe alternative approach for post-operative analgesia, with low post-operative opioid requirements and facilitation of same-day discharge.
BN SO63 - A systematic review of Hiatus Hernia classifications
Authors: Barratt Owain , Badenoch Thomas , Findlay John
Published: November 2024

Background

Hiatus hernias (HH) are common, an important cause of symptoms, and a strong risk factor for complications and oesophageal dysplasia and adenocarcinoma. However, there is a lack of consensus as to how they should be classified. This has significant implications for benchmarking and standardising practice, as well as generating and answering research questions. The aim of this review was to systematically identify and appraise what classification systems have been described, and to identify any novel approaches to HH classifications and their association with treatment outcomes.

Method

We undertook a systematic review of the PubMed and EMBASE databases on the 17th January 2023. Inclusion criteria were any studies containing a HH classification described within adults. Exclusion criteria were studies not in English, animal studies and case reports.

Results

847 articles were identified. 245 were included, with a further 9 studies identified that tested a novel approach to classifying HH against surgical outcomes. Most classification systems (64.9%) were anatomical, but with significant variation as regards stratification of size of the hernia, and its contents (primarily the proportion of herniated stomach). A small number of classifications described endoscopic, manometry, symptomatic and intra-operative classifications. There was considerable heterogeneity in the definitions used for larger HH. The quality of studies comparing classifications with outcomes was limited; however, some possible associations were reported based on anatomical and physiological parameters.

Conclusion

We found a wide range of HH classification systems. These were mainly anatomical and based on the traditional type I-IV system. Whilst the evidence is limited, it seems likely that other components (anatomical and physiological) may have utility in better classifying HH and guiding treatment, standardisation and research.