bluuebunny/crossref_metadata_2025 huggingface dataset:
P-EGS16 Lemmel Syndrome due to Duodenal Diverticulitis, an Infrequent Cause of Biliary Obstruction
Authors: Natale Joseph , Abdelrahman Mohamed , Wheatley Timothy
Published: December 2021

Background

Lemmel syndrome, first described in 1934, is the presence of biliary obstruction as a consequence of duodenal diverticula. The precise aetiology remains uncertain. Multiple causative theories have been proposed. These include mechanical biliopancreatic duct occlusion, functional disruption of the sphincter of Oddi and alteration of the course of the distal biliary and pancreatic ducts. We present a case of biliary obstruction caused by diverticulitis of a solitary duodenal diverticulum. 

Methods

A 71-year-old woman with no co-morbidities presented with early satiety, cachexia and upper abdominal pain.  An epigastric mass was palpable, alkaline phosphatase was 247 iu/L, alanine transaminase 124iu/L, bilirubin 4umol/L and C-reactive protein 68mg/L. Computed tomography (CT) of the abdomen and pelvis revealed obstructed biliary tree with D2 duodenal diverticulitis. Magnetic resonance cholangiopancreatography (MRCP) displayed a causative enterolith. Treatment with antibiotics was initiated and the patient commenced on liquid diet. Liver function tests and inflammatory markers normalised. After a seven day admission patient was discharged and oral intake normalised. Interval MRCP revealed resolution of obstruction and inflammation.

Results

Duodenal diverticula occur in 1-20% of individuals. Complications are symptoms are uncommon. Diverticulitis is a rare complication. Malignancy and cholelithiasis should be excluded in diagnostic workup. The mainstay of therapy for duodenal diverticulitis is conservative. CT and MRCP are effective diagnostic tools. Diverticulectomy carries substantial risk of morbidity and mortality. Endoscopic sphincterotomy or lavage have a role in relief of biliary obstruction when present. Comparative prospective studies of management do not exist and retrospective enquiry is sparse. Management is thereby best determined clinically on a case by case basis. Surgery is reserved for failed conservative and medical therapy.

Conclusions

Duodenal diverticulitis should be considered in patients with unexplained upper abdominal pain and elevated inflammatory markers. In combination with obstructive jaundice, suspicions should be raised for acute inflammation causing obstruction to the biliary tree. Cross sectional imaging is useful in determining the diagnosis. Antibiotics and conservative therapy are prudent first line management in the absence of perforation. Where these measures are inadequate endoscopic and operative strategies may be employed but have no robust evidence basis.
P-EGS18 The outcomes of upper gastrointestinal bleeds with unsuccessful endoscopy in a district hospital with no interventional radiology
Authors: Wintrip Dorothy
Published: December 2021

Background

Acute upper gastrointestinal bleeding (UGIB) is a common emergency estimated to occur in 80 to 150 out of 100,000 people each year. First line management is endoscopy and pharmacological but those who fail this can pose a challenge. Current NICE guidelines recommend repeat endoscopy to patients who re-bleed, those unstable consider interventional radiology (IR) or emergency surgery. The estimated mortality rate is approximately 10%. This study was conducted to review our current surgical outcomes and whether referral for IR is appropriate and could reduce mortality.

Methods

Retrospective study of 11 patients who underwent surgery for refractory non- variceal UGIB between November 2015 and March 2021 with a mean age of 61. Data was collected from the electronic records.

Results

All patients underwent an emergency laparotomy, 82% had an ASA of 4 the remainder ASA 3, a mean NELA mortality of 31.1% and a mean Blatchford 11.1. The initial OGD was performed on the day of admission in 54% of patients. 45% during initial OGD became hemodynamically unstable and transferred to theatre, one patient re-bleed 3 days after and taken to theatre the remainder (45%) re-bleed and had a 2nd OGD. 2 patients unstable during OGD went to theatre, 3 re-bleed within 24hrs 1 within 48hrs and taken to theatre. Mortality rate was 27%, complication rate 45%, mean LOS 24.6.

Conclusions

These findings highlight the high rate of morbidity and mortality associated with surgical treatment for UBIB. A small number of cases occurred over 7 years requiring surgical intervention,45% had two OGD’s and 9% went on to have a 3rd. Was there a window of opportunity to use IR if it were available. Recent studies have shown that transcatheter arterial embolization is safer than surgical intervention in the high risk patient population and has a lower 30-d mortality rate.
P-EGS26 Outcomes of Surgical Treatment for Perforated Peptic Ulcer in a non-Upper Gastrointestinal Surgery Centre
Authors: Firdaus Azhar , Han Lai Jun , Xuan Sam Chi , Yunus Alif , Ahmad Khairol Ashraf , Ming Yap Lee
Published: December 2021

Background

Perforated peptic ulcer (PPU) remains a common surgical emergency worldwide requiring surgical intervention. Although commonly performed, morbidity and mortality rate remained high. This study aimed to analyze the factors that contribute to the outcome of PPU surgery in a non-upper gastrointestinal surgery center in Malaysia.

Methods

Data were collected by retrospective review of all PPU surgeries done throughout the year 2020, looking into various preoperative, intraoperative, and postoperative details.

Results

In this study, we have a total of 24 PPU patients underwent surgery resulted in 7 (29.2%) deaths. Majority of our subjects were elderly (median age 65 years, IQR 48.5 – 73.0) with 4 (16%) being of ASA (American Society of Anesthesiologist) category 3 - 4. The most common cause of death was uncontrolled systemic infection in 4 patients (57.1%), followed by 2 (28.6%) fatal arrhythmia and 1 (14.3%) massive upper gastrointestinal bleed. Our analysis found that size of perforation ≥ 30mm (OR = 0.18, 95%CI 0.08 - 0.44), and postoperative complications (OR = 12.5, 95%CI 1.6 – 97.6) were significantly associated with a higher postoperative death. Low serum albumin level (mean 34.3 ± 9.1g/L), negative base excess level (mean -3.28 ± 4.89), and prolonged interval between admission and commencement of surgery (median 750 mins, IQR 258 – 2218) were all significantly associated with increased mortality post PPU surgeries. 

Conclusions

This study highlighted to us various perioperative factors which could potentially be modifiable thus necessary measures can be taken in the future to ensure a better operative outcome of PPU surgery.
P-EGS28 Management of obstructive jaundice secondary to gall stones in an ambulatory setting
Authors: Boag Katie , Amtul Nasira , Roy Pratik , Singh Rahulpreet , Kandiah Shivanthi , Toogood Giles , Ahmad Aman
Published: December 2021

Background

Our data from Leeds shows a 30% increase in patient attendance to the Surgical Assesment Unit (SAU) across a 5 year period, putting unprecedented demands on the acute surgical service. A new Ambulatory Surgical Centre (ASC) was established for the advancement of ambulatory care pathways that would ensure that acute patients are seen promptly and kept safe with monitoring in an appropriate setting without needing admission to the hospital bed base. Gallstone related disease accounts for a third of patient attendance to the emergency surgical services. We present our experience with an ambulatory pathway to manage patients with obstructive jaundice caused by gall stones, and propose a protocol driven pathway.

Methods

The ASC operates an acute, consultant led clinic, with access to urgent blood tests and dedicated USS, CT and MRI imaging capacity, and offers a direct referral service from Primary Care Networks (PCNs) through the Primary Care Access Line (PCAL). Patients referred with clinical jaundice or RUQ/Epigastric pain are investigated for derangement in their liver function, and assessed for the presence and severity of Acute Cholangitis (AC), according to the 2018 Tokyo Guidelines. Patients without evidence of cholangitis, or with AC Grade I are planned for management in the ambulatory setting, including investigations, monitoring and endoscopic/surgical intervention. Outcome data was collected retrospectively from PCAL data source, spanning from Oct 2020 till July 2021.

Results

A total of 98 patients were referred to the acute surgical service during this period. Out of these, 47% had Grade II (n = 35) or Grade III (n = 17) AC. 48% were suitable for ambulatory management, with no evidence of AC(n = 5) or Grade I AC(n = 43). 20% patients were found to have a cause other than gall stone disease. 55% have undergone intervention (33 Laparoscopic cholecystectomies, 22 ERCP) while 12 are on the waiting list for surgery.

Conclusions

Our protocol offers a safe, comprehensive and timely pathway for the management of patients with gall stone related obstructed jaundice in an ambulatory setting. This has helped reduce the demand on hospital beds for surgical patients.
P-L09 Pyogenic Liver Abscess: a Retrospective Study of Patients Presenting to a UK Tertiary Liver Centre
Authors: Sams Emily , Duncan Patricia , O'Reilly David , Alessandri Giorgio , Parry Craig , Kumar Nagappan
Published: December 2021

Background

Pyogenic liver abscess (PLA) carries a significant mortality of between 2-12%. The incidence is higher in East Asia than in Western countries, and recent data looking at PLA in western populations is limited. Increasingly, we find that PLA is primary in the liver rather than from a secondary source, even in the western world. The aim of this retrospective study is to analyse data on presentation and outcomes of PLA at a UK tertiary liver centre.

Methods

Data was collected on patients diagnosed with a PLA and treated at the University Hospital of Wales, Cardiff between December 2010 and December 2020. Patients were identified by searching the Cardiff Liver Unit surgical database and Radiology database using the search term “liver abscess”. Patients with an abscess secondary to gallbladder perforation into the liver were excluded. Data was gathered using the available electronic health records, including  comorbidities, mode of presentation, cause of PLA, microbiology, treatment received (surgical, radiological drainage, or antibiotic therapy), and outcomes.

Results

There were 86 patients with a median age of 69 (16-91), Male:Female ratio was 2:1. Main symptoms were abdominal pain and fever; 61.6% (n = 53). Treatment was surgical in 49% (n = 42), US guided drainage in 21% (n = 18) and antibiotics only in 30% (n = 26). Mortality was 9.3% (n = 8), with a median age of 76, significantly higher than survivors (p = 0.012). In this group, Male:Female ratio was 7:1; proportion with >2 co-morbidities was 62%, compared with 39% of survivors; and there was a greater delay in diagnosis (average 4 days versus 2 days in survivors), although these factors were not statistically significant.

Conclusions

PLA is a serious infection that can lead to mortality. Forty percent of patients can present with non-specific symptoms and early imaging in this group is essential for diagnosis. In our cohort, significant number of patients were treated with surgery compared to the literature, with good outcomes.  Although the numbers are small to be statistically significant, delayed diagnosis, multiple comorbidities, and male gender confer an increased risk of mortality, as does advanced age. We conclude that early diagnosis and referral to a Liver centre for opinion or management is essential for optimal outcomes.
P-O06 A scoring system to support surgical decision-making for cardial submucosal tumors
Authors: Geng Zi-Han , Zhu Yan , Chen Wei-Feng , Li Quan-Lin , Zhou Ping-Hong
Published: December 2021

Background

Submucosal tunneling endoscopic resection (STER) and non-tunneling techniques are two alternative options for the treatment of cardial submucosal tumors (SMTs). We aimed to establish a regression model and develop a simple scoring system to help clinicians make surgical decisions for cardial submucosal tumors.

Methods

A total of 246 patients who suffered cardial SMTs and received endoscopic resection were included in this study. All of them were randomized into the training cohort (n = 147) or internal validation cohort (n = 99). Then, the scoring system was proposed based on multivariate logistic regression analysis in the training cohort and assessed in the validation cohort.

Results

Of 246 patients, 97 were treated with STER, and the others with non-tunneling endoscopic resection. In the training stage, four factors were weighted with points based on the β coefficient from the regression model, including irregular morphology (-2 points), ulcer (2 points), the direction of the gastroscope (-2 points for reversing direction and 1 point for entering direction), and originating from the muscularis propria (-2 points). The patients were categorized into low-score (< -4), medium-score (-4 - -3) and high-score (> -3) groups, and those with low scores were more likely to be treated with STER. Our score model performed satisfying discriminatory power in internal validation (Areas under the receiver-operator characteristic curve (AUC), 0.829; 95% confidence interval (CI), 0.694-0.964) and goodness-of-fit in the Hosmer-Lemeshow test (P = .4721).

Conclusions

This scoring system could provide clinicians the references for making decisions about the treatment of cardial submucosal tumors.
P-O08 Effect of socioeconomic deprivation on clinical characteristics and outcomes of patients undergoing an emergency appendectomy
Authors: Miller Gillian , Khan Khurram , Gall Lewis , AlAzzawi Y , Macdonald Andrew
Published: December 2021

Background

Appendicectomy is one of the commonest emergency general surgical operations performed.  Previous studies have shown that socioeconomic status (SES) impact outcomes in a number of diseases.  Currently, there is no study analysing the impact of SES on the outcome of appendectomy.   Our aim was to compare the clinical characteristics and outcomes of adults having an emergency appendectomy between deprived and less deprived SES groups.  

Methods

A multicentre retrospective observational study of all adult patients who had an emergency appendectomy across four hospitals (two district general and two tertiary care hospitals) between August 2018 and November 2020 was performed.  Patients were identified through pathology records.  Data was extracted from electronic records for demographics, pre-operative (peak) blood results, pre and post-operative imaging, operative details and the clinical outcomes.  Patient’s residential address was used to calculate Scottish Index of Multiple Deprivation (SIMD).  The patients were grouped by SIMD into a more deprived SES group (SIMD 1-5) and a less deprived SES group (SIMD 6-10) and results compared.

Results

A total of 1,105 patients (57.5% male) were included.  Median age was lower in the more deprived group (35 vs 40 years, p < 0.001).   The less deprived group were more likely to be fitter: ASA-1 grade 51.6% vs 43.5%, p = 0.008.  There were fewer appendectomies in most deprived decile compared to the least deprived decile (5.2 vs 11.3 per 10,000 population per year, p < 0.001).   There was no difference in inflammatory markers, pre-operative imaging, surgical approach, severity of appendicitis and the median length of stay (3 days).  However, there were more surgical site infection in the more deprived group (3.4% vs 0.9%, p = 0.006).

Conclusions

This study demonstrates that SES does impact on the age of presentation and incidence of appendectomy.  Surgical site infection were seen more frequently in the more deprived patients undergoing emergency appendectomy.  This may be a reflection of the underlying comorbidities.
P-O15 “Knife to Skin” time: The invariable variable
Authors: Michel Martin , Fifer Helen , Moran Emily , Bonner Clare , Hammett Felix , Khawgali Mohamed , Kronberga Madara , Saab Ala , Balbola Mohamed , Saha Arin
Published: December 2021

Background

The Covid-19 pandemic has affected all aspects of healthcare globally. Theatre utilisation assumes a substantial proportion of hospital resources, creating a streamlined pathway increases efficiency and productivity. With concerns regarding aerosol generating procedures, viral transmission to health care workers in theatre and patient pathways through the hospitals the covid-19 pandemic has added another dimension to the theatre pathway. The aim of this study was to quantify the impact of Covid-19 on the “knife to skin” (KTS) time and compare it to previous historical data (HD).  

Methods

Retrospective analysis of real time theatre data was analysed for the first 12 months of the pandemic from 11th March 2020 to 11th March 2021. To try and minimise variability between different specialities and operations we picked one operation to study: Laparoscopic cholecystectomy (LC). Historical data was also gathered from the same time frame over the last 5 years (2015-2020) for comparison. Data collected included emergency or elective, time sent for patient, anaesthetic start time, knife to skin time and duration of operation. Comparison of means were analysed by One-way ANOVA tests and Student’s T-Test.

Results

399 laparoscopic cholecystectomies were performed during the first year of the pandemic. KTS time was calculated as operation start time minus time sent for patient.  Average time during the pandemic for emergency LC KTS was 56 minutes and 35 minutes for elective LC. Comparison of these times to HD revealed no statistical difference (Emergency LC 56 mins vs 58 mins p > 0.05, Elective LC 35 mins vs 35 mins p > 0.05). The anaesthetic time for emergency LC during the pandemic vs HD was 10 mins vs 14 mins (p < 0.05), no statistical difference was found in the elective group, 16mins vs 14mins (p > 0.05)

Conclusions

The Covid-19 pandemic has had no detectable effect on Knife to skin time as compared to our previous historical data. It seems the extra Covid 19 precautions involving PPE, pathways etc. have not affected theatre efficiency or utilisation. In fact, there was very little variance in KTS time over the six years studied (2015-2021) with very consistent levels for both elective and emergency procedures. The shorter anaesthetic time for emergency LC during the pandemic needs to be further investigated but one hypothesis is the unconscious or conscious decision to decrease the amount of preoxygenation to minimise aerosolisation.
P-OGC01 Prevalence and treatment of nutritional deficiencies following Upper Gastrointestinal Surgery for Oesophageal or Gastric Cancer
Authors: Dossou Vida , Murphy Amy
Published: December 2021

Background

Patients undergoing Upper Gastrointestinal (UGI) surgery for cancer are left nutritionally vulnerable due to alterations in digestion and absorption this is becoming increasingly evident as more patients are achieving five year survival. 

Patients are more likely to endure nutritional deficiencies in particular B12, Iron, Vitamin D, Calcium, Zinc and folic acid. 

Reduced absorption and inadequate dietary intake of calories, protein and micronutrients are the main contributing factors post operatively and longer term. 

At 2 years post UGI resection the following nutritional deficiencies have been observed: 48% Iron, 42% B12, 40% Folic Acid, 34% Calcium, 33% Zinc, 24% Vitamin D.

Methods

Data was collected retrospectively from various systems on our Trusts Network. 

The trusts reporting system was utilised for blood results. 

Digital systems were used to confirm if any action had been taken and if this was appropriate. Additional digital systems were used to obtain clinic lists for the last 6 months. 

The Data was collected and entered into an Excel spread sheet for comparison. 

Chi squared testing was utilised to compare deficiency rate between different Upper GI surgeries. 

Results

Chi squared statistical analysis of the nutritional deficiencies in the three main Cancer surgery types (Ivor Lewis / Total OG / Sub-total OG) found there was no statistical difference in prevalence of nutritional deficiency. 

Comparison of deficiencies indicated that the main prevalence was or Zinc and Vitamin D pre and post operatively.  

Conclusions

Nutritional deficiencies should be corrected pre operatively. Monitoring thereafter of nutritional vitamin and mineral status should be individually tailored to suit the patient. 

All UGI patients should be commenced on a nutritionally complete vitamin and mineral supplement at the point of initial assessment in the UGI surgical clinic pre operatively. 

The recommendation would be to commence Forceval vitamin and mineral supplement as this offers optimal trace element coverage. 

Vitamin D deficiency pre operatively should have supplementation to maintain 25(OH)D levels greater than 50nmol/L and rechecked after 3 months. Zinc replacement should be monitored routinely.
P-OGC12 Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes
Authors: Bull Alexander , Pucher Philip , Maynard Nick , Underwood Tim , Lagergren Jesper , Gossage James
Published: December 2021

Background

Over 1,500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation.

Methods

An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data

Results

Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions.

Conclusions

Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.
P-OGC13 Chest drainage after oesophageal resection: A systematic review
Authors: Bull Alexander , Pucher Philip , Lagergren Jesper , Gossage James
Published: December 2021

Background

Modern enhanced recovery protocols discourage drain use due to negative impacts on patient comfort, mobility, and recovery, and lack of proven clinical benefit. After oesophagectomy, however, drains are still routinely placed. This review aimed to assess the evidence for, and how best to use chest drains after oesophageal surgery.

Methods

A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases. Studies reporting outcomes for different types or uses of thoracic drainage, or outcomes related to drains after trans-thoracic oesophagectomy were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed with Newcastle-Ottawa and Jadad scores.

Results

Among 434 potentially relevant studies, 27 studies met the inclusion criteria and these included 2564 patients. Studies that examined the number of drains showed pain reduction with a single drain compared to multiple drains (3 studies, n = 103), and transhiatal placement compared to intercostal (6 studies, n = 425). Amylase levels may aid diagnosis of anastomotic leak (9 studies, n = 888). Narrow calibre Blake drains may effectively drain both air and fluid (2 studies, n = 163). Drain removal criteria by daily drainage volumes of up to 300ml did not impact subsequent effusion rates (2 studies, n = 130). Complications related directly to drains were reported by 3 studies (n = 59).

Conclusions

Available evidence on the impact of thoracic drainage after oesophagectomy is limited, but has the potential to negatively affect outcomes. Further research is required to determine optimum drainage strategies.
P-OGC18 Does cardiopulmonary testing help predict long-term survival after oesophagectomy?
Authors: Chmelo Jakub , Khaw Rachel A , Sinclair Rhona C F , Navidi Maziar , Phillips Alexander W
Published: December 2021

Background

Oesophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes within major surgery. Variables derived from CPET have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing oesophagectomy is associated with long-term survival. The aim of this study was to evaluate whether any of the cardiopulmonary exercise testing (CPET) variables that are routinely derived in patients with oesophageal cancer may aid in predicting long-term survival after oesophagectomy.

Methods

Patients undergoing CPET followed by trans-thoracic oesophagectomy for oesophageal cancer with curative intent between January 2013 and January 2017 from single high-volume centre were retrospectively analysed. The relationship between predictive co-variables including CPET variables, and survival was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was conducted to find cut-off values for CPET variables predictive of 3-year survival.

Results

A total of 313 patients were analyzed. The ventilatory equivalent for carbon dioxide (VE/VCO2) at anaerobic threshold was the only CPET variable independently predictive of long-term survival in multivariable analysis (HR 1.049, 95% CI 1.011-1.088, p = 0.011). Pathological stage III and IV disease was the other co-variable found to be independently predictive of survival. ROC analysis of the VE/VCO2 failed to demonstrate a predictive cut-off value of 3-year survival (AUC=0.564, 95% CI 0.499-0.629, p = 0.056).

Conclusions

A high VE/VCO2 before oesophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for consideration when counselling patients.
P-OGC22 Incidence and relevance of clinically indeterminate non-regional lymph nodes in the treatment of oesophageal cancer
Authors: Pucher Philip , White Annabelle , Padfield Olivia , Davies Andrew , Maisey Nick , Qureshi Asad , Subesinghe Manil , Baker Cara , Gossage James
Published: December 2021

Background

Metastatic involvement of non-regional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare, but has important implications for prognosis and management.  The management of non-regional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimetre nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up, and clinical significance of non-regional clinically indeterminate FDG avid lymph nodes.

Methods

A single centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted.  Patients with mid- or distal oesophageal cancer with non-regional FDG avid nodes were identified.  Subsequent work-up, management, and outcomes were retrieved from electronic health records.

Results

Reports for 1189 PET-CT scans were reviewed.  A total of 79 patients met the inclusion criteria.  Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery, and underwent further assessment.  The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine needle aspiration (US-FNA) in 100% of cases.  15/18 (83.3%) of samples were benign and proceeded to surgery.  Outcomes for patients who proceeded to surgery were similar to other cohorts.  None had pathology suggesting false negative lymph node sampling.

Conclusions

EBUS and US-FNA are effective means of sampling clinically indeterminate non-regional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued.
P-OGC24 Comparison of the histopathological regression after neoadjuvant FLOT versus ECX in resectable gastroesophageal adenocarcinoma
Authors: Prasad Pooja , Chmelo Jakub , Brown Joshua , Bradshaw Alexander , Fergie Bridget , Wahed Shajahan , Phillips Alexander
Published: December 2021

Background

Neoadjuvant chemotherapy is a key component in the treatment of resectable oesophagogastric cancer (OGC). Histopathological tumour regression is associated with a prognostic benefit in OGC. There is increased usage of the FLOT regimen as part of neoadjuvant chemotherapy (NAC) for these tumours. The initial phase 2 trial demonstrated complete pathological response (pCR) in 15% for FLOT versus 6% for ECX but there is no data outside a trial setting. The aim of this study was to evaluate the differences in pCR and the extent of downstaging between patients receiving FLOT versus ECX in the neoadjuvant setting. 

Methods

Consecutive patients treated for OGC in a single, high-volume UK centre between 2018 and 2021 were identified from a contemporaneously maintained database. Patients underwent 3 cycles of ECX or 4 cycles of FLOT as part of NAC. Histopathological tumour regression was assessed by the Mandard classification. A comparison of T- and N stage migration between FLOT and ECX was performed. Major pCR was defined as TRG 1-2 based on the Mandard classification.

Results

The study included 162 patients. 6/84 (7.1%) patients receiving ECX and 5/78 (6.4%) patients receiving FLOT achieved a pCR (p = 0.853). 11/84 (13.1%) patients in the ECX group and 12/78 (15.4%) patients in the FLOT group achieved a major pCR (p = 0.677).

With regards to stage migration by T-stage, 36 (42.9%) patients were downstaged and 6 patients (7.1%) were upstaged with ECX. Amongst FLOT patients, 42 (53.8%) were downstaged and 8 (10.3%) upstaged (p = 0.189). When comparing N-stage, 29 (34.5%) patients achieved downstaging and 28 (33.3%) were upstaged with ECX. 30 (38.5%) patients were downstaged and 20 (25.6%) were upstaged with FLOT (0.563). 

Conclusions

There was no significant difference in pCR and stage migration rates between patients receiving neoadjuvant ECX and FLOT. pCR rates were lower than previously reported, and it is unclear if the difference in prognosis will translate comparable outcomes between patients receiving ECX versus FLOT.
P-OGC26 Learning curves in minimally invasive esophagectomy- a systematic review and evaluation of benchmarking parameters
Authors: Prasad Pooja , Wallace Lauren , Navidi Maziar , Phillips Alexander
Published: December 2021

Background

Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive oesophagectomy (MIO) is variable and can impact on patient outcomes. The aim of this study was to review the current evidence on learning curves in MIO and identify which parameters are used for benchmarking.

Methods

A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used. 

Results

Twenty-nine studies comprising 3741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid and total MIO, 6 studies reported robotic assisted MIO (RAMIE) alone and 1 study evaluated both RAMIE and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity and blood loss also frequently used. Learning curves were found to plateau at 7-60 cases for thoracoscopic esophagectomy, 12-175 cases for total and thoracoscopic/hybrid esophagectomy and 9-85 cases for RAMIE. 

Conclusions

Multiple parameters are employed to gauge MIO learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be utilised to ensure best patient outcomes and required length of proctoring.
P-OGC35 Does Adjuvant Chemotherapy Provide Additional Survival Benefit AfterNeoadjuvant Chemotherapy or Chemoradiotherapy and Esophagectomy forEsophageal Adenocarcinoma?
Authors: Kamarajah Sivesh , Markar Sheraz , Phillips Alexander , Kunene Victoria , Fackrell David , Salti George , Dahdaleh Fadi , Griffiths Ewen
Published: December 2021

Background

The evidence assessing the additional benefits of adjuvant chemotherapy (AC) following neoadjuvant therapy (NAT; i.e. chemotherapy or chemoradiotherapy) and esophagectomy for esophageal adenocarcinoma (EAC) are limited. This study aimed to determine whether AC improves long-term survival in patients receiving NAT and esophagectomy.

Methods

Patients receiving esophagectomy for EAC following NAT from 2004 - 2016 were identified from the National Cancer Data Base (NCDB). Patients with survival < 6 months were excluded to account for immortality bias. Propensity score matching (PSM) and Cox regression was performed to account for selection bias and analyze impact of AC on overall survival.

Results

Overall 12,972 (91%) did not receive AC and 1,255 (9%) received AC. After PSM there were 2,485 who received AC and 1,254 who did not. After matching, AC was associated with improved survival (median: 38.5 vs 32.3 months, p < 0.001), which remained after multivariable adjustment (HR: 0.78, CI 95% : 0.71 - 0.87, p < 0.001). On multivariable interaction analyses, this benefit persisted in subgroup analysis for nodal status: N0 (HR: 0.85, CI 95% : 0.69 - 0.96, p = 0.039), N1 (HR: 0.66, CI 95% : 0.56 - 0.78, p < 0.001), N2/3 (HR: 0.80, CI 95% : 0.66 - 0.97, p = 0.024) and margin status: R0 (HR: 0.77, CI 95% : 0.69 - 0.86, p < 0.001), R1 (HR: 0.60, CI 95% : 0.43 - 0.85, p = 0.004). Further, patients with stable disease following NAT (HR: 0.60, CI 95% : 0.59 - 0.80, p < 0.001) or downstaged (HR: 0.80, CI 95% : 0.68 - 0.95, p = 0.009) disease had significant survival benefit after AC, but not patients with upstaged disease.

Conclusions

AC following NAT and esophagectomy is associated with improved survival, even in node-negative and margin-negative disease. NAT response appears crucial in identifying patients who will benefit maximally from AC, and thus future research must be focused on identifying tumors that respond to chemotherapy to maximize this prognostic benefit.
P-OGC42 Hiatus Hernia following Minimally Invasive Oesophagectomy - a Single Centre Experience
Authors: Rana Mridul , Sanga Akshata , Mastoridis Sotiris , Sgromo Bruno
Published: December 2021

Background

Hiatus hernia is an established complication following oesophagectomy, with a higher incidence when a minimally invasive approach (MIO) is undertaken. Literature reports the incidence post-MIO to be vary between 4.5% -26%. There is no clear consensus on the optimum operative management of this complication. The aim of this study was to establish the incidence of hiatus hernia post MIO (HiHO) at a single hospital site, identify predisposing factors, and evaluate subsequent surgical management of this complication.

Methods

Single-center data were retrospectively analysed of MIOs conducted consecutively between May 2018 and October 2020. A minimum follow-up period of 6 months was required for inclusion. HiHO was defined by radiological confirmation. Data collected included patient demographics, comorbidities, risk factors for hiatus hernia and patient’s post-operative course. Statistical analyses were performed using Fischer’s exact or independent t-test as appropriate.

Results

50 patients who underwent MIO were included; mean follow up of 1.92 years. 7 (14%) presented with HiHO. There was no significant difference in age or gender between patients with and without HiHO. HiHO patients had a significantly lower BMI (95% CI 1.083-8.271; P = 0.012) and were more likely to have underlying lung conditions (P = 0.029). A higher incidence of pre-existing hiatus hernia was present among the HiHO group (43% vs 21%). Of those developing HiHO, 6 (86%) were symptomatic requiring surgical reduction with crural repair of hiatus or colopexy; 2 had a recurrence of HiHO requiring subsequent colopexy.

Conclusions

This study represents the largest single centre analysis of hiatus hernia post minimally invasive oesophagectomy. Our results correlate with the literature, that there is a significant risk of hiatus hernia following minimally invasive oesophagectomy. This risk is increased among patients with pre-operative hiatus hernia, low BMI, and pre-existing lung conditions. Crural repair or colopexy are options for surgical management of HiHO. Colopexy may potentially prevent recurrence of HiHO. A larger study size and a consensus from experts in the field would be beneficial in guiding operative management of HiHO to improve patient outcomes.
P-OGC44 Multi-omic cohort study of Barrett’s oesophagus reveals structural variation and retrotransposon activity to occur early in cancer evolution
Authors: Katz-Summercorn Annalise , Jammula Sriganesh , Frangou Anna , Peneva Iliana , O'Donovan Maria , Tripathi Monika , Malhotra Shalini , Pietro Massimiliano di , Abbas Shujath , Devonshire Ginny , Januszewicz Wladyslaw , Blasko Adrienn , Nowicki-Osuch Karol , MacRae Shona , Northrop Alex , Redmond Aisling , Wedge David , Fitzgerald Rebecca
Published: December 2021

Background

Barrett’s oesophagus (BE) is the main risk factor for the development of oesophageal adenocarcinoma (OAC), yet few patients ever go on to progress to cancer. The acquisition of events during the metaplasia-dysplasia-cancer sequence is poorly characterised. We present a large, unbiased, multi-omics analysis of a cross-sectional cohort of pre-cancer samples, with the aim of providing a comprehensive insight into the diversity and molecular changes driving the disease to cancer.

Methods

We generated and integrated the genomic (50x), transcriptomic and epigenomic (850K EPIC array) landscapes of snap-frozen endoscopic biopsies from 146 patients with a range of outcomes (27 long-standing non-dysplastic; 12 prior to progression to dysplasia; 14 low-grade; 25 high-grade; 21 intramucosal carcinoma; 47 cases of BE taken adjacent to OAC) and 642 person years of follow-up. All biopsies were reviewed independently by 3 pathologists and had associated annotation with detailed clinical information.

Results

The total number of structural variants (SV) captured the most variance between samples. Complex SVs and LINE-1 retrotransposon activity were observed even before dysplasia had developed and increased with progression. Increasing SV burden was associated with chromothripsis (12%, 18/146) and breakage-fusion bridges (BFBs; 8%, 13/146). In more than 50% of these, the BFBs were in chromosome 17, harbouring the oncogenes ERBB2 and CDK12, for which expression was significantly higher. With progression there was increased expression of genes related to cell-cycle checkpoint, DNA repair and chromosomal instability, and the epigenetic silencing of genes in WNT-signalling and cell-cycle pathways.

Conclusions

Genomic complexity occurs very early in the natural history of BE and increasing genomic instability appears to tip the balance towards cancer. This may inform the potential for progression to cancer beyond the clinically discernible phenotype. Efforts to better understand the triggers for chromosomal breakages and rearrangements that underly progression will aid clinical prediction and prevention strategies.
P-OGC49 Reporting on Patient and Public Involvement in Oesophago-gastric Research Trials using the GRIPP 2 checklist
Authors: Musbahi Aya , Immanuel Arul
Published: December 2021

Background

There is increasing evidence on the value of PPI reporting (patient public

involvement) in all research. GRIPP2 (Guidance for Reporting Involvement of Patients and the Public) is the first international guidance for reporting of patient and public involvement in health and social care research. Associations with improved relevance and applicability may reduce research waste and target research funds more appropriately. The aim of this study was to review the reporting of PPI amongst all oesophago-gastric clinical trials undertaken between 2015 and 2021.

Methods

An electronic search in databases Medline, Embase and the Cochrane Library was

conducted to identify all clinical trials pertaining to oesophagogastric cancer from 2015 to 2021(with the exception of reviews, case reports and conference abstracts). Articles were scanned by two authors to identify if reporting of PPI had taken place. 

Results

A total of 334 studies were found, of which 285 met the inclusion and exclusion criteria.Only 4 studies had reported on PPI. Two of which reported positive involvement and two reported negatively. None of the studies reported using the GRIPP 2 checklist and when reported by this study, none achieved all points on the GRIPP2 SF checklist. An analysis on the extent of PPI involvement in these studies was carried out. 

Conclusions

PPI is poorly reported across oesophago-gastric research trials.
P-OGC51 A Review of Post-Oesophagectomy Benign Anastomotic Strictures
Authors: Musbahi Aya , Immanuel Arul
Published: December 2021

Background

Benign anastomotic strictures (BAS) are a known risk of oesophageal resection, leading to significant post-operative morbidity and a reported incidence of BAS varies widely from 8.83% to 42.38%. This review aims to assess incidence, risk factors for development as well as treatment. 

Methods

An electronic search using specific search terms using Medline, Embase and the

Cochrane Library to identify all articles studying the development of BAS in adults post

oesophagectomy was carried out. Inclusion criteria were patients who underwent any form of oesophagectomy for malignant disease (Ivor Lewis, McKeown, thoracoabdominal, transhiatal,minimally invasive); patients in study >18-year-old; study reported only benign anastomotic strictures and any study design with a minimum of 6 patients. Only articles published in the English language were included. Review articles, case reports and conference abstracts were all excluded

Results

Seven studies reported on the incidence of BAS and an average of 34.1% was found. Cervical anastomosis, anastomotic leak development. Cardiovascular disease, diabetes and gastric conduit and smaller gun size in a stapled anastomosis were also found to be associated with BAS. Hypertension, neoadjuvant chemotherapy, transhiatal oesophagectomy or transthoracic were not found to be associated with BAS. The mainstay of management appears to be endoscopic balloon dilatation with adverse reported outcomes related to stent management.

Conclusions

BAS after oesophagectomy is common. Several risk factors have been identified and balloon dilatation appears to be the mainstay of treatment.
P-OGC55 Current treatment modalities and median survival for patients with gastric and oesophagogastric cancers with isolated peritoneal metastasis
Authors: Ma Adler Shing Chak , Lam Stephen , Otify Eman , Yousfi Abdulfatah , Stearns Adam , Kumar Bhaskar
Published: December 2021

Background

Gastric cancer with peritoneal metastases carries a median survival of only 3-7 months without treatment. Meanwhile, cancers arising from the oesophago-gastric junction (OGJ) are rapidly increasing in incidence in the Western population and are also commonly associated with peritoneal metastases. In order to measure the efficacy of emerging modes of treatment for peritoneal disease, it is essential to describe the treatments patients currently receive and the impact of these on survival – data for which is poorly described in the literature and lacking in the UK setting.

Methods

This was a single hospital-based retrospective cohort study covering the period from March 2012 to January 2020 at a tertiary referral centre. 50 patients were identified from multidisciplinary team (MDT) meeting records receiving a diagnosis of gastric adenocarcinoma with isolated peritoneal disease. 31 patients were identified receiving a diagnosis of true (Siewert II or III) junctional adenocarcinoma with isolated peritoneal disease. We calculated median survival time for all patients and also by treatment modality.

Results

Mean age of patients with gastric adenocarcinoma and isolated peritoneal disease was 71 years (range 44-90). Overall median survival was 6.6 months (IQR 2.4-19.3). Median survival was 11.2 months (IQR 3.7-21.5) for patients receiving systemic chemotherapy (n = 26) and 2.4 months (IQR 1.2-5.1) for patients receiving best supportive care alone (n = 15).

Mean age of patients with junctional adenocarcinomas and isolated peritoneal disease was 70 years (range 37-89). Overall median survival was 7 months (IQR 3-19). Median survival was 10.5 months (IQR 6.5-20.5) for patients receiving systemic chemotherapy (n = 20) and 3.5 months (IQR 2-6) for patients receiving best supportive care alone (n = 6).

Conclusions

Our results demonstrate the poor prognosis of both gastric and oesophagogastric cancer patients with isolated peritoneal disease. Prognosis figures are comparable between the two cancer types. Findings are in line with previous studies performed outside the UK which have shown that available treatments extend survival by no more than 3-9 months, highlighting the desperate need for new treatment modalities.