bluuebunny/crossref_metadata_2025 huggingface dataset:
BN SO18 - Considering Physiology Surveillance in Patients with Oesophageal Atresia
Authors: Miah Ismail , Wong Terry , Gossage James , Jafari Jafar
Published: November 2024

Background

Oesophageal atresia (OA) is a congenital malformation found between one in every 2,400 to 4,500 new-borns per year world-wide [1] who require immediate oesophageal surgery and lifelong endoscopic surveillance for complications of gastroesophageal reflux, oesophagitis, Barrett's oesophagus, anastomotic strictures, oesophageal dysmotility and dysphagia [2, 3].

This study investigates whether ad-hoc oesophageal physiology surveillance would be clinically beneficial for patients with post OA surgical history.

Method

Retrospective study was conducted on patients with surgical history for OA and undergone oesophageal physiology studies between 2010 and 2023. 11 patients were found (6 females) who had oesophageal physiology at mean age of 29 years (95% CI 26.7 to 35.3 years) or correspondingly post-surgery for OA.

Standard high-resolution manometry assessment was re-interpreted with reference Chicago Classification(version 4.0)[4]. This followed by stimulation with multiple water swallowing and solid bolus swallows as adjunctive testing [5, 6, 7].

This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800).

Results

Major dysmotility was observed in 7 patients (63.6%)(achalasia 3, absent contractility(AC) 4) and minor dysmotility was apparent in 4 patients (ineffective oesophageal motility [IOM]). Development of major dysmotility was at a later onset post-surgery to minor dysmotility (30.4 years vs 26.5 years, p=0.214). As was achalasia to AC (32.3 years vs 29.0 years, p=0.379).

Adjunctive testing augmented oesophageal smooth muscle contractility in all patients with IOM and invoked remaining neuromuscular functioning in 2 patients with AC. The achalasia diagnosis in the 3 patients remained unchanged during the adjunctive testing.

Conclusion

Oesophageal physiology surveillance in patients with post OA surgery would enable identifying the staging of the motility disorder and which may direct further surgical management. This study revealed patients were still suitable for partial fundoplication post OA surgery (54.5%) and surgical myotomy for achalasia (27.3%).

The prevalence of achalasia (27.3%) and absent contractility (36.4%) in post OA surgery observed this study are significantly higher compared to the non-OA treatment-naïve patients found in the general population living with achalasia and absent contractility disorders.

References

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564549/

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11093930/ (1)

[3] https://pubmed.ncbi.nlm.nih.gov/27579697/

[4] https://onlinelibrary.wiley.com/doi/10.1111/nmo.14058

[5] https://gut.bmj.com/content/66/Suppl_2/A270.2

[6] https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2982.2011.01682.x

[7] https://doi.org/10.1038/ajg.2013.289
BN SO26 - Predicting successful and safe day-case laparoscopic cholecystectomy: Validation of the Cholecystectomy as a Day Case (CAAD) score
Authors: Mamareli Christina , Craig Carol , Rajkomar Kheman
Published: November 2024

Background

Day case surgery is a major target for the NHS as it improves patient satisfaction and reduces financial costs. The CAAD score, using pre-operative variables from clinic letters and electronic sources, aids in selecting patients for day-case lists. This study assessed the validity of the CAAD score in predicting successful and safe day-case laparoscopic cholecystectomy (LC) at an isolated day unit.

Method

A retrospective analysis was performed on patients scheduled for elective LC between January 2020 and March 2022. Outcomes (same day discharge rate, length of stay, conversion to open, bile leak, mortality) were stratified by CAAD score (≤5, >5). Statistical analyses included Chi square and independent t-tests using SPSS 28.0.

Results

58 patients were analysed.18/38 patients with CAAD ≤5 achieved same day discharge compared to 4/20 with CAAD >5 (p<0.05).

36 patients stayed for ≥1 day. The mean length of hospitalization was 1.38 days (range 1-2) for the 13 patients with CAAD ≤5. 15 patients with CAAD >5 stayed significantly longer i.e. 2.53 days (range 1-10) (p <0.05).

Longer stay for scores >5 was due to difficult dissection (13%), conversion to open (13%) and drain insertion (7%). For scores ≤5, reasons were drain insertion, postoperative pain, nausea, and difficult dissection, each at 8%. No major complications were noted in either group.

Conclusion

The CAAD score is a predictive tool for successful and safe day-case LC, correlating lower scores with higher success rates and shorter hospital stays. Implementing the CAAD score can improve patient selection, potentially reduce unnecessary overnight stays, and support operational efficiency in isolated day units.
BN SO29 - Overinvestigation and unnecessary surgery for Gallbladder Polyps: An audit of compliance with ESGAR guidelines
Authors: Blackburn Jessie , Farksas Nicholas , Crotty Fiona , Miller Freya , Belgaumkar Ajay
Published: November 2024

Background

Incidental gallbladder polyps are increasingly reported on abdominal ultrasound and have a theoretical association with increased risk of gallbladder cancer. Most gallbladder polyps are actually gallstones and there is little evidence for any survival benefit or reduced rates of gallbladder cancer in patients under ultrasound surveillance. ESGAR guidelines attempt to standardize and rationalize surveillance protocols, balancing the risks of missed early cancers versus the costs of surveillance investigations. This audit aims to assess the investigation and management of gallbladder polyps as per ESGAR guidelines at a single NHS trust.

Method

An audit was conducted at a single NHS Trust in England. Searches were conducted on the electronic patient record for patients coded for K82.8 (Gallbladder pathology: other) from 01/01/2022 to 31/12/2023. Patient records were examined for radiological imaging confirming diagnosis of gallbladder polyp. Data was analysed using Microsoft excel and compared with the 2021 ESGAR guidance on management of gallbladder polyps.

Results

97 patients were included. All polyps were diagnosed with abdominal ultrasound. Patients had, on average, two ultrasounds. 51% were seen in outpatients clinic. 35 patients (36%) underwent laparoscopic cholecystectomy (including all patients with a polyp >10mm). Histology confirmed diagnosis of cholecystitis (69%), pseudopolyp (9%), gallbladder polyp (6%) and IPMN (3%). 74% (26/35) of patients that underwent cholecystectomy had biliary symptoms and 77% (20/26) had cholecystitis confirmed by histology. Despite having biliary symptoms at first assessment, 47% of polyp patients went on to have two ultrasounds and two clinic appointments.

Conclusion

The study confirms that the majority of ultrasound detected polyps are not neoplastic, and patients undergo multiple hospital visits, incurring significant non-therapeutic costs. Adherence to ESGAR guidelines is inconsistent. In the symptomatic cohort, however, a low threshold for laparoscopic cholecystectomy should be considered given the high likelihood of underlying stones.
BN SO34 - Outcomes in giant versus non-giant hiatus hernia repair: Same payment different operative burden
Authors: Sinha Yashashwi , Howey Caitlin , Nandra Saroop , Thorne Thomas , Fernando Tyrrel , Akbari Khalid , Tan Lam Chin , Menon Vinod , McLaughlin Euan
Published: November 2024

Background

Hospital trust payment for operative procedures often rely on coding systems like the NHS's Office of Population Censuses and Surveys (OPCS) codes, which determine reimbursement rates. Both giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs often share the same code, as in our trust. This results in equal reimbursement to trusts for procedures with higher operative burden and resource needs. This study aims to assess differences in the patient population, their hiatal type, operative challenges and post-operative outcomes between GHH and NGHH repairs.

Method

All patients undergoing primary hiatus hernia surgery between March 2019 to March 2024 at a single institution were included. Retrospective review of electronic records were utilised to record: patient demographics, hernia type, operative details, length of stay (LOS), post-operative course and need for a return to theatre (RTT). Outcomes were comparison of surgical approach, use of mesh and gastropexy (as proxy measures to indicate difficulty of operation), 30-day morbidity measured using Clavien-Dindo (CD) grading and 30-day mortality and RTT. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant.

Results

Table 1. Patients GHH NGHH p n 91 135 Age (average) 69 (±10) 52 (±16) <0.001 Female (%) 66.7 55.2 0.1100 BMI 30.8 (±5.4) 30.7 (±7.8) 0.2029 ASA grade (average) 2.2 1.9 <0.001 Hernia Types (median) 3 1 <0.001 Table 2. Operative details GHH NGHH p Open (%) 6.6 0 0.0020 Laparoscopic (%) 60.4 62.24 0.9840 Robotic (%) 33 33.3 0.9239 Mesh used (%) 8.8 0.7 <0.041 Gastropexy (%) 12 0.7 <0.001 Table 3. Outcomes GHH NGHH p LOS (median) 2 (0-161) 1 (0-8) 0.0179 RTT (%) 10.7 8 0.4747 30-day morbidity (CD≥3, %) 4.8 4.4 0.6519 30-day mortality 0 0 NA

Conclusion

This study highlights significant differences between giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs. GHH repairs have an increased likelihood of undergoing open procedures, use of mesh, and gastropexy, reflecting their greater complexity. GHH patients are older, have higher ASA grades, and present with more advanced hernia types compared to NGHH patients. Additionally, GHH repairs result in longer hospital stays.

The findings underscore the need for improved coding accuracy to reflect these disparities accurately in patient demographics, operative strategies, and recovery outcomes within hospital trusts, ensuring appropriate resource allocation and reimbursement based on procedural complexity.
BN SO42 - Our experience of Emergency Laparoscopic Fundoplication in a DGH
Authors: Khan Amnah Ilyas , Mostafa Omar , Sellahewa Chaminda
Published: November 2024

Background

Emergency presentation of hiatal hernias can be life-threatening and is associated with high morbidity and mortality rates. Elective Laparoscopic hiatus and paraoesophageal hernias are commonly performed with fundoplication. However, emergency cases are often repaired without an anti-reflux procedure. We present our experience of emergency Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication in a District General Hospital (Russells Hall Hospital, RHH).

Method

6 cases of diagnosed hiatus/ paraoesophageal hernia that underwent Emergency fundoplication from 2019-2024.

Results

The mean age of the patients was 74 (56-83). All patients had a pre-op CT scan to confirm the diagnosis. 4 patients (66%) had a Type 3 Hiatus hernia and 2 (33%) had a Type 2 classic paraosephageal hernia. All patients underwent Emergency Laparoscopic Hiatus / Para oesophagal hernia repair with fundoplication. 2 patients required mesh for the repair. The mean length of stay was 5 days (3-7). There were no intra or post-op complications and on follow up 1 patient had a recurrence of symptoms after 1 year requiring redo fundoplication.

Conclusion

The choice of operation is mainly based on the patient’s clinical condition, the complexity of the hernia and the surgeon’s experience. Our experience at RHH shows that Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication is safe and feasible in patients with emergency presentation.
HPB SO03 - Preoperative biliary drainage prior to pancreaticoduodenectomy for pancreatic head malignancy: Guidelines versus the reality
Authors: Hammoda Mohammed , Yarwood Adam , Al-Sarireh Bilal
Published: November 2024

Background

British guidelines currently advise against routine preoperative biliary stenting (PBS) unless patients have cholangitis or organ failure secondary to biliary obstruction. If stenting is required, self-expanding metal stents are advocated. Using a large multicentre cohort, this study aimed to investigate the proportion of patients who underwent PBS prior to pancreatoduodenectomy (PD) and describe the approach used.

Method

Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for histologically confirmed pancreatic head malignancy (29 centres from 8 countries, n=1484). Patients who underwent PBS were identified and the details surrounding this were obtained.

Results

1482 patients had data on use of PBS. 427 didn't undergo PBS, 1055 underwent attempted PBS. Of the latter, 989 had a stent placed successfully, 38 had PBS failed , and 28 had an external biliary drain . when PBS performed, Among 857 were primary endoscopically placed , 75 had percutaneously placed PBS having failed endoscopy , and 50 had a primary percutaneously placed PBS . 755 patients known stent material ( 66% were plastic, 34% metal). In 671 who had data regarding cytology from PBS known, 48% had cytology suggestive/diagnostic of malignancy, 25% had inadequate histology, and 28% did not send a cytology sample.

Conclusion

Despite guidelines advising against routine PBS, over two thirds of PD patients in our study underwent stenting. Despite guidelines advocating metal stents when PBS is necessary, two thirds of the stents deployed were plastic. Stent cytology has a low sensitivity for pancreatic head malignancy.
HPB SO08 - Safety of Robotic cholecystectomy as index training procedure – the UK experience
Authors: Stefanova Irena , Alkhatib Omar , Sheel Andrea , Alabraba Edward , Alibrahim Mohammad , Arshad Ali , Awan Altaf , Baron Ryan , Bhatti Imran , Bhogal Ricky , Dhakshinamoorthy Vijayanand Vijayanand , Diaz-Nieto Rafael , Dunne Declan , Frampton Adam E , Green Alexander , Hajibandeh Shahin , Hamady Zaed , Horgan Liam , Kissane Eleanor , Krishnan Sailakshmi , Kumar Rajesh , Lahiri Rajiv , Lam Shi , Liau Siong-Seng , Marangoni Gabriele , Moudghalya Shyam , Papadopoulos Georgios , Pencavel Tim , Picker Sarah , Ramsingh Jason , Riga Angela , Silva Michael , Soonawalla Zahir , Subar Daren , Sud Vikas , Upasani Vivek , Wong Vincent , Worthington Tim , Yeung Kai Tai Derek , Ahmad Jawad
Published: November 2024

Background

A recent large retrospective cohort study reported a higher risk of bile duct injury associated with robotic cholecystectomy when compared to the laparoscopic approach. Considering that most robotic training pathways, including the one followed in the UK, utilise robotic cholecystectomy as index training procedure, such findings mandate evaluation of the safety profile of robotic cholecystectomy in the UK to ensure its use as an alternative approach to laparoscopic cholecystectomy is not putting patients at risk. We aimed to conduct a multi-centre observational study to evaluate the safety profile of robotic cholecystectomy performed within the UK HPB Robotic training program.

Method

A retrospective analysis of prospectively collected data from eleven centres participating in the UK robotic HPB training program was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters.

Results

A total of 600 patients were included. The median age was 53 (IQR 65 - 41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600) and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR: 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600).

Conclusion

This current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low conversion to open surgery and low need for subtotal cholecystectomy.
HPB SO22 - Clinical outcomes following radical cholecystectomies, a single centre experience in review
Authors: Mohamed Eyas , Mascarenhas Chrystle , Arora Arvind , Zaitoun Abed , Gomez Dhanny
Published: November 2024

Background

Gallbladder carcinoma (GBC) is a rare disease with dismal prognosis. The majority of cases are identified at an advanced state that preclude curative approaches which would usually necessitate removal of the gallbladder with en-block wedge hepatectomy of segment 4b/5 as well as periportal lymphadenectomy. The purpose of this study was to analyze our outcomes for patients undergoing a radical cholecystectomy for suspected GBC.

Method

A retrospective analysis of patients who underwent radical cholecystecomies at Queen’s Medical Centre, Nottingham, UK between 1st January 2014 and October 2023 was performed. Patients with concomitant primaries, incidental GBC or completion liver resection following index cholecystectomy were excluded.

Results

41 patients were eligible for analysis, those were comprised of 13 males and 28 females with a median age of 67 (IQR 57-72) years. The incidence of malignancy on histology was 31.7% (GBC n=11, metastatic renal carcinoma n=1, metastatic melanoma n=1). Cystic margin assessment by frozen section was performed in 41% of cases.

In cases with confirmed gallbladder cancer, the median tumour size was 30mm, positive periportal lymph nodes were identified in two patients while R0 resection was achieved in all cases.

The median length of stay following surgery was 5 days (IQR 5-7) while Clavien Dindo complication grade ≥ III were experienced in 12% ( return to theatre for leak from repaired cholecysto-duodenal fistula n=1, IR drainage of post operative collection n=3, ITU stay for cardiac arrhythmia n=1).

The pathologies encountered in benign cases (n=28) were compatible with chronic cholecystitis (53.5%, n=15), concurrent chronic cholecystitis and adenomyomatosis (21.4%, n=6), xanthogranulomatous cholecystitis (10.7%, n=3), adenomyomatosis (7.1%, n=2), follicular cholecystitis (3.5%, n=1), benign GB polyps (3.5%, n=1).

Conclusion

Radical cholecystectomy remains the standard of care for suspected GBC however sufficient preoperative counselling is prudent given likelihood of benign disease on histology.
HPB SO24 - Recurrence Pattern of Pancreatic Ductal Adenocarcinoma based on Time-to-Recurrence: A 5-year Single-Centre Retrospective Study
Authors: Patel Agastya , Kitching Samuel , Barker Sharon , Lancellotti Francesco , Kadamapuzha Jacob , Satyadas Thomas
Published: November 2024

Background

A vast majority of patients with pancreatic ductal adenocarcinoma (PDAC) develop early disease recurrence, even after curative-intent surgical resection. Understanding the pattern of disease recurrence will enable identification of areas for improvement within the preoperative diagnostic and management algorithms for these patients. The aim of the retrospective cohort study was to compare the recurrence pattern of PDAC in patients with early (<12 vs >12 months) and very early (<6 vs >6 months) recurrence following surgical resection.

Method

A retrospective review of histologically confirmed pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy (N=151) between 2015-2020 at a tertiary HPB centre was undertaken. All patients underwent CT and PET-CT for initial staging before resection. Initial recurrence after resection was identified through postoperative imaging and/or HPB MDT outcomes. Early recurrence (ER) was defined as recurrence within the first 12 months after surgery (n=78). Additionally, very early recurrence (VEM) was defined as recurrence within the first six months after surgery (n=46). Statistical analysis was performed using GraphPad Prism 8.0.

Results

In total, 117 (77.5%) of patients experienced recurrence, with a median recurrence-free survival of 11.3 (5.1-19.6) months. Patients with ER had significantly higher pathological T staging (p=0.01), greater margin positivity rate (p=0.01) and higher lymph node ratio (p=0.046), while those in VER had significantly larger maximum tumour diameter and number of involved lymph nodes (p=0.04) compared to their counterparts. Patients with ER (47.4 vs 31.5%, p=0.046) and VER (60.9 vs 30.5%, p<0.001) had significantly greater rates of liver metastasis compared to their counterparts. There were no differences in loco-regional recurrence, peritoneal or pulmonary metastasis between the groups.

Conclusion

Approximately 20% of patients undergoing surgical resection for PDAC developed liver metastasis within six months of surgery. This raises concerns for the presence of micro-metastatic disease within the liver unidentified on preoperative imaging. Therefore, there is a need to enhance preoperative imaging and treatment algorithms to improve survival of patients with PDAC.
HPB SO28 - Pre-operative Biliary Drainage in Pancreatic Adenocarcinoma and its Effect on Surgical Oncological Outcomes
Authors: Shehata Zak , Subar Daren
Published: November 2024

Background

Pre-operative biliary drainage (PBD) in patients undergoing pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been associated with a significantly increased risk of serious complications. This retrospective study investigated if PBD has a significant effect on lymphovascular (LVI) or perineural (PNI) invasion compared to direct surgery (DS).

Method

Data was collected retrospectively from patients undergoing PD for PDAC from 01/01/2014 to 30/12/2022. Patients were grouped according to whether they received any form of PBD or not. Patients’ T and N stage, as well as lymph node ratio (LNR), R status, Mortality, disease free (DFS) and overall survival (OS) were recorded. The primary outcome measure was lymph node ratio.

Results

A total of 87 patients were identified (48 PBD group vs 39 DS group), with a mean age of 68. The median LNR was 0.2 in PBD vs 0.21 in DS Group (p=0.87). There was no significant difference in median DFS (310 days PBD vs 285 DS p=0.94) or median OS (513 days PBD vs 515 DS p=0.39). PBD was not associated with a greater incidence of LVI (67% PBD vs 69% DS p=0.8), or PNI (94% PBD vs 97% p=0.41). PBD did not have a significant effect on resection margin status (p=0.75).

Conclusion

Despite evidence in the literature on its effects on the rate of complications, PBD has not been shown to have an effect on LVI or PNI, disease progression, nor overall survival in our patient group.
HPB SO31 - A 3rd cycle quality improvement project on reducing unnecessary investigation, improves patient satisfaction and optimises cost-efficiency in a tertiary general surgical unit caring for patients with acute pancreatitis
Authors: Kwan Yi Xin , Teoh Yong Xuan , Carr Harry , Kanakala Venkatesh
Published: November 2024

Background

Acute pancreatitis (AP) is a serious and potentially life-threatening systemic disease. Guidelines recommend that a diagnosis may be established if the patient has any two of1:a typical clinical history/examinationserum amylase >3 times the upper limit of normalRadiological (CT) evidence consistent with AP

Once established, further repeat amylase testing is not indicated and does not guide management, nor provide prognostic value2. Previous QIP cycles carried out in James Cook University Hospital (JCUH) between 2021-2023 showed that 47% of patients with established AP had repeated amylase done unnecessarily. Interventions were implemented in JCUH and re-evaluated.

Method

The present QIP is a third cycle retrospective evaluation of the number of repeat serum amylase tests performed on patients with a diagnosis of AP, between 01/10/2023 to 21/01/2024. Of a total 1368 patients admitted, 63 patients (n=63) were identified for inclusion, by confirming their diagnosis of AP within their discharge letters. Data collection was completed by reviewing electronic notes and investigation results on our local investigations platform (WebICE). 1 year prior to data collection the intervention, a ‘pop-up', was implemented into WebICE to invite the clinician to consider if the repeat amylase test requested was clinically indicated before proceeding.

Results

Of the 63 patients identified, 100% had serum amylase tested on admission and were diagnostic in 62% of patients. 19 patients (30%) had amylase re-requested, a significant decrease from 47% in previous cycles. Among the patients with repeat amylases requested, 7 patients had amylase repeated twice. None of the documented indications to repeat amylase were clinically justified, with the most common indication being ‘for monitoring’. When comparing to cycles 1 and 2, we saw an improvement in the mean rates of amylase re-requesting from 2.4/patient, down to 1.37/patient in cycle 3 (Figure 1).

Figure 1 – Mean rates of repeat amylase per patient across all QIP cycles to date

Conclusion

Our simple intervention, a ‘pop-up’ in our investigations requesting platform, resulted in a significant improvement over previous cycles, reducing the burden on our laboratories, costs of our general surgical service and improving patient satisfaction during their admission. However, there are still repeated amylases being performed without clear indication or patient benefit. Further interventions should be considered including, increasing awareness among healthcare personnel and re-evaluating and enhancing the effectiveness of the pop-up reminder in our local requesting platform. Re-evaluation will be completed in 6-12 months’ time.
HPB SO33 - Transcriptomic characterisation of the diabetogenic pancreatic ductal adenocarcinoma phenotype
Authors: Stott Martyn , Hasoon Megan , Oldfield Lucy , Soul Jamie , Halloran Christopher , Costello Eithne
Published: November 2024

Background

New-onset diabetes mellitus (NOD) can manifest as a consequence of pancreatic ductal adenocarcinoma (PDAC), although not all PDAC patients develop NOD. For many patients, hyperglycaemia begins 3 years prior to PDAC diagnosis, with 30% of PDAC patients experiencing NOD by the time their cancer is diagnosed. The mechanisms underlying the onset of diabetes mellitus (DM) in PDAC and its consequences for disease development, detection and treatment are not well understood. The aim of this study was to characterise the transcriptomic differences between PDAC tumours that present with NOD compared to those that do not.

Method

Eight tumour samples from patients undergoing surgery for PDAC (4 without DM (HbA1c <35), 4 with NOD (HbA1c >65, within 3 years of cancer diagnosis) underwent single cell-RNA sequencing (scRNAseq) after taking intra-operative biopsies using Chromium 10X Genomics technology. Unique cell clusters were identified using CellRanger and cell types annotated using scATOMIC and singleR datasets. Manual annotation was undertaken when results were not agreeable after consulting the literature. Differential expression between groups was performed using DESeq2. Significant genes were identified as having a log2 fold-change >1.5 and p<0.05. Gene set enrichment was performed using Reactome. Analysis was conducted in RStudio.

Results

Single cell suspensions were created with a mean cell count of 1.2 million cells and a mean viability of 90%. PDAC cells and the full complement of tumour microenvironmental cells were recovered. Significant differential expression was seen in the PDAC cells themselves, CD4+ cells, macrophages, mast cells and fibroblasts. Cancer associated fibroblasts (CAFs) seemed not to differ. PDAC cells with NOD seemed to be enriched in MYC oncogenes whereas those without DM seemed to be enriched in KRAS mutations. There was a mixture of “basal” and “classical” transcriptional subtypes between the two groups.

Conclusion

Differences between diabetogenic PDAC and non-diabetogenic PDAC have been observed at the transcriptional level. Diabetogenic tumours seem to be promoted by MYC oncogenes and be more inflammatory than non-diabetogenic tumours. These findings require validation which will be done on independent samples using spatial transcriptomics to allow endocrine-exocrine crosstalk to be determined. Understanding the molecular pathways in diabetogenic pancreatic tumours could enhance future strategies to detect PDAC earlier and to target diabetes-associated vulnerabilities for therapeutic purposes.
HPB SO38 - Assessing current pancreatic cancer reporting practice against the PACT-UK Synoptic Reporting Template: An initial clinical audit
Authors: Patel Agastya , Edy Elbert , Lancellotti Francesco , Kadamapuzha Jacob , Satyadas Thomas
Published: November 2024

Background

In the last decade, the incidence of pancreatic cancer has increased by 9% in the UK. The gold standard for initial assessment of pancreatic cancer (or even peri-ampullary cancer) resectability is pancreatic-protocol CT scan. The PACT-UK project introduced a synoptic template for pancreatic cancer to standardise CT reporting practice across UK and enable consistent reporting of pertinent aspects of resectability status such as vascular involvement of the tumour. The aim of this audit is to assess the quality of current CT reports received by a tertiary hepato-pancreato-biliary (HPB) unit against the standards set out by PACT-UK.

Method

A retrospective analysis of 66 patients who underwent pancreatic resection between September 2023 and May 2024 at a tertiary HPB centre was undertaken. Patients were excluded from the analysis if they underwent resection for benign pancreatic pathology, were diagnosed with pathology other than peri-ampullary cancer or did not have a formal report of their CT scan. Initial CT scans performed at presentation and if available, subsequent up-to-date staging scan prior to surgery were assessed against the PACT-UK reporting template, in accordance with their guidance. The audit was registered with our clinical audit team (no. 11643).

Results

In total, 42 patients with peri-ampullary cancers were included in this audit. All patients had a reported CT scan on presentation. Additionally, 24 patients had a reported staging CT scan. The compliance (i.e. more than 90% information available) with PACT-UK reporting standards was 0% for initial presentation scans and 4.2% (n=1) for staging scans. The only staging scan with >90% compliance was reported using the PACT-UK template. Majority (more than 80%) of CT scan reports lacked information on aspects such as pancreatic duct size, predicted tumour type and radiological stage, variant vascular anomalies, and arterial/venous involvement.

Conclusion

This audit highlights the substandard quality of current CT reporting for peri-ampullary cancer. There is an urgent need to adopt a structured and dedicated reporting template to address the issue. Utilising a template such as the one developed by PACT-UK will help ensure that relevant information is formally reported to facilitate optimal decision-making at MDT meetings, and assist surgeons in operative planning and oncologists in assessing treatment response.
HPB SO40 - Implementation of Biodegradable Stents in HPB and Transplant Surgery: A Systematic Review to assess adherence to the IDEAL framework
Authors: Hall Lewis , Fox Sebastian , Sarodaya Varun , Halle-Smith James , Roberts Keith , Smith Andrew , Pathak Samir
Published: November 2024

Background

Biodegradable stents are a novel device in HPB and liver transplant surgery, to potentially mitigate anastomotic dehiscence. The IDEAL (idea, development, exploration, assessment, long-term study) framework provides a formal method of evaluation for novel surgical procedures. This study explores adherence to the IDEAL guidance for the adoption of biodegradable stents in HPB and liver transplant surgery and explores governance procedures, patient selection, technique description, quality assurance measures, and outcome reporting.

Method

A systematic review of PUBMED, MEDLINE and Embase databases identified studies investigating use of biodegradable stents in HPB and liver transplant surgery. Data extracted included: study characteristics, governance procedures, patient selection, technique description, surgeon expertise, and outcome reporting.Where studies reported an IDEAL stage, it was recorded, and where not recorded, a validated tool was used by these authors to assign a stage to included studies.

Results

Of 736 records screened, nine studies were included (seven in pancreatic surgery and two in liver transplant). The biodegradable stent reported most often was the Archimedes™ stent (AMG Int., Winsen-Germany; six of nine studies). All studies failed to implement the IDEAL framework. Eight studies were classified retrospectively as IDEAL 2a and one as IDEAL 1. Five of nine studies detailed ethical approval. Patient selection and technique description were heterogenous. No studies reported surgeon expertise and outcome reporting was varied.

Conclusion

To date, the IDEAL framework has not been adhered to in the adoption of biodegradable stent use in HPB and liver transplant surgery. Study design, technique description, and outcome reporting were heterogenous. Any further work should endeavour to adhere to the IDEAL framework when reporting.
HPB SO41 - Does Adjuvant Chemotherapy Provide a Survival Benefit in Elderly Patients (≥70 years) with Pancreatic Cancer? A Retrospective Cohort-study
Authors: Solomon Rosie , Patel Agastya , Kitching Samuel , Barker Sharon , Lancellotti Francesco , Kadamapuzha Jacob , Satyadas Thomas
Published: November 2024

Background

There is currently conflicting evidence surrounding the use of adjuvant chemotherapy (AC) for elderly patients (over 70 years) with pancreatic adenocarcinoma. Limited existing studies debate its effect on overall survival (OS) and relapse-free survival (RFS). The aim of this study is to assess whether adjuvant chemotherapy following pancreaticoduodenectomy provides a survival benefit in elderly patients with pancreatic cancer.

Method

A retrospective review including elderly adult patients, seventy years and older, who underwent a Whipple’s pancreatoduodenectomy for pancreatic adenocarcinoma between 1st January 2015 and 31st December 2020, at a tertiary HPB centre was performed. Information on baseline characteristics, preoperative assessment, histopathology, postoperative complications and course, and adjuvant chemotherapy were collected. Elderly patients who received AC were compared to those who did not undergo AC. Statistical analysis was performed using Jamovi 2.3.

Results

Sixty-eight patients were included with 44 (65%) receiving AC. There was no difference in age (p=0.72), sex (p=0.19), preoperative characteristics (all p<0.05), and resection margin (p=0.67) between the groups. There was no difference in complication rates (p=0.20), including Clavien-Dindo3+ (p=0.68). The length of hospital stay was shorter in the AC group, without statistical significance (15.7±11.9 vs 23.2±20.3 days, p=0.06). There was no difference in RFS between the groups (22.7±20 vs 15.4±23.6 months, p=0.18). However, patients who received AC had a significantly greater OS compared to those who did not (30.7±18.2 vs 18.6±22.2 months, p=0.02).

Conclusion

AC improved overall survival in elderly (≥70 years) patients with pancreatic adenocarcinoma. Whilst many elderly patients may not receive adjuvant chemotherapy due to postoperative complications and/or longer hospital stay, our study suggests age alone should not be a deciding factor when considering adjuvant chemotherapy in this cohort. A future large, multicentre prospective study is needed to further examine OS with the use of AC in elderly patients with pancreatic adenocarcinoma.
HPB SO47 - Adjuvant chemotherapy for early pancreatic cancer: Meta-analysis of survival benefit and the need for a national study of UK practice
Authors: Athwal Tejinderjit , Evans Daisy
Published: November 2024

Background

Stage I pancreatic cancer is defined as disease localised to the pancreas (T1-T2, N0, M0). Whilst landmark trials have demonstrated adjuvant chemotherapy (AC) improves survival in resectable disease, early stages comprise only 3-8% of cases. The benefit of AC in stage 1 pancreatic cancer is yet to be defined and there currently exists no data outlining the use of AC for early disease in the United Kingdom (UK). We aimed to perform a meta-analysis evaluating comparative outcomes of pancreatic cancer resection with or without AC in patients with stage I pancreatic cancer and outline plans for a national collaborative study.

Method

A systematic search of MEDLINE, CENTRAL and Web of Science and bibliographic reference lists were conducted. All comparative studies reporting outcomes of pancreatic cancer resection for stage I cancer with or without AC were included and their risk of bias were assessed using ROBINS-I tool. Survival outcomes were analysed using hazard ratio (HR) and odds ratio (OR) for the time-to-event and dichotomous outcomes, respectively.

Results

We included six studies reporting 6,874 patients with resected stage 1 pancreatic cancer of whom 3,951 patients had no AC and the remaining 2,923 patients received AC. The use of AC was associated with significantly higher overall survival (HR 0.71, P<0.00001) and 2-year survival (65.1% versus 57.4%, OR 1.99, P=0.04) compared to no use of AC. There was no statistically significant difference in 1-year (86.8% versus 78.4%, OR 1.60, P =0.25), 3-year (46.0% versus 44.0%, OR 1.07; P =0.43), or 5-year survival (24.8% versus 23.3%, OR 1.03; P =0.81) between the two groups.

Conclusion

Meta-analysis of best available evidence (level 2a with low to moderate certainty) demonstrates that AC may confer survival benefits for stage I pancreatic cancer when compared to the use of surgery alone. National evaluation of the use of AC within the UK is currently lacking but is necessary. Randomized control trials are required to escalate the level of evidence and confirm these findings with consideration of contemporary chemotherapy agents and regimens.
HPB SO48 - Evaluating the timeframe for the provision of laparoscopic cholecystectomy in acute cholecystitis patients at a regional hospital
Authors: Tan Hao Ming , Tan Jia Xuan , Aleem Khalid Atta U L , Hemadri Makani
Published: November 2024

Background

Acute biliary disease comprised a substantial proportion of the general emergency surgical workload. AUGIS and NICE guidelines recommend early laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) patients as it is associated with reduced readmission rates, healthcare costs and faster recovery without notable complication risks. According to the local trust policy, it advocates early LC to be performed within 72 hours of admission for AC patients. If this is not possible a delayed LC should be performed within 8 weeks of admission. Our aim is to examine variations in the provision of LC between current practice and local trust/ NICE guidelines.

Method

This is a retrospective audit looking at the total number of surgical patients diagnosed with AC between Jan and Dec 2023. The number of patients who had LC in 2023, unfit for surgery and did not consent for the procedure were also included. This data was obtained from electronic patient records (investigative reports, discharge letters, outpatient letters) and then collated on a Microsoft Excel sheet for analysis. Surgical patients who were not diagnosed with AC such as those with biliary pancreatitis, cholelithiasis or cholangitis but subsequently underwent LC were excluded.

Results

The number of AC patients who were fit and consented to surgical intervention in 2023 was 88. The total number of delayed procedures done was 75 (85.2%). The number of patients who had early LC within 1 week was 13 (14.8%).

Of the 75 patients who had delayed LC, 19 (25.3%) patients had delayed LC within 8 weeks from the diagnosis date. The remaining 56 (74.7%) patients had delayed LC after 8 weeks.

For patients who had delayed LC, the readmission rate within 6 months of their discharge while waiting for their operative dates was 29 (38.7%).

Conclusion

One-third of AC patients were readmitted while waiting for LC, some had complications of gallstone disease such as perforation/ gallstone ileus. Therefore, the early provision of LC is crucial in minimising the readmission and complication rates. This data was highlighted in a departmental meeting and teaching session for consultants and junior doctors. We plan to liaise with stakeholders and theatre managers in implementing further solutions to improve compliance where possible. One critical area is auditing the condition of surgical patients in order to be put on the hospital’s twice-weekly hot gallbladder list to consider prioritising AC patient surgical time.
HPB SO54 - Outcomes of Isolated Bile Duct Resection for Cholangiocarcinoma; More Than 15 Years Experience in a Single Tertiary HPB Centre
Authors: Alnagar Amr , Ayoub Rami , Sutcliffe Robert , Marudanayagam Ravi , Keith Robert , Chatzizacharias Nikolaos , Dasari Bobby , Raza Syed , Bartlett David
Published: November 2024

Background

Cholangiocarcinoma of the extrahepatic biliary tree usually requires a major resection to achieve clear margins with adequate lymphadenectomy. For perihilar tumours this involves extended liver resection with bile duct resection whilst distal tumours require pancreaticoduodenectomy. Occasionally a combination of both (hepato-pancreaticoduodenectomy) is required. These procedures are associated with high morbidity and mortality. In a small number of patients, cholangiocarcinoma is confined to the extrahepatic bile duct with no involvement of the liver or pancreas and a bile duct resection alone is an option. We reviewed the outcomes of patients who underwent bile duct resection for cholangiocarcinoma in our unit.

Method

We identified all patients who underwent bile duct resection and hepaticojejunostomy for cholangiocarcinoma between June 2007 and June 2023 in our centre from a prospectively maintained database. Patient demographics, complications, histology, resection margin status, follow-up, recurrence, and survival were recorded. Time to recurrence and overall survival were analysed using Kaplan Meier analysis.

Results

Thirteen patients underwent bile duct resection and hepaticojejunostomy for cholangiocarcinoma. 12 (92%) were male and the median (range) age was 72 (41-82). No patients received neoadjuvant treatment. 3 (23%) patients developed postoperative complications with 1 (7.7%) perioperative mortality. R0 margin was achieved in 6 (46%). The median (range) postoperative stay was 7 (5-25) days. 8 (61.5%) patients received adjuvant chemotherapy. 7 patients (53.8%) developed recurrent disease at a median of 12 (IQR 8-54) months following surgery. The most common sites of recurrence were the liver (23.1%) followed by local recurrence (15.4%). The median survival was 38 (IQR 20-95) months.

Conclusion

Extrahepatic bile duct resection with hepaticojejunostomy is an option for patients with cholangiocarcinoma of the extrahepatic bile duct without macroscopic involvement of the liver or pancreas. In our series this procedure was associated with a low morbidity and perioperative mortality with acceptable recurrence rates and overall survival despite only modest R0 resection rates. Isolated bile duct resection with hepaticojejunostomy should be considered for tumours without macroscopic involvement of the liver or pancreas, especially in patients of borderline fitness for a more extensive resection.
HPB SO56 - Prompt prescription of fluids and analgesia for acute pancreatitis and evaluation of subsequent laparoscopic cholecystectomy: A Quality Improvement Project
Authors: Cheong Jeremy , Lee Shiela , Jha Madan
Published: November 2024

Background

Pancreatitis is a common presentation for General Surgery department nationally. Treatment of these patients are timely initiation of analgesia and fluid resuscitation. Patients with gallstone pancreatitis should have inpatient cholecystectomy as per the NICE Guidance. Delays in treatment of acute pancreatitis can worsen mortality and morbidity rates. We aim to assess if patients have been given fluid, analgesia, VTE prophylaxis promptly upon admission and if they had laparoscopic cholecystectomy in the index admission for those with gallstone pancreatitis.

Method

Single centre retrospective cohort of patients, above 18 years old, who presented to general surgery services from November 2022-23. Patients need to have radiological evidence of pancreatitis or raised amylase above 150. Patients were evaluated for prompt prescription of analgesia, fluids and VTE prophylaxis within 24 hours based on our ePrescription system. Evaluation of laparoscopic cholecystectomy service was also performed to assess if patients had the surgery during the indexed admission or within 30 days of discharge.

Results

99 patients with median age of 60 was included. Only 3 patients required higher levels of care in HDU or ITU. The median length of stay was 5 days. 96% had analgesia prescribed, 91% had VTE prescribed but only 81% had fluids. Of those who did not have fluids within 24 hours, the average lenght of stay was 5.5 days and only 1 patient needed to be admitted to intensive care unit. 26 patients had gallstone pancreatitis but 15% had laparoscopic cholecystectomy performed. Our readmission rate was 6% and 30-day mortality was 1%.

Conclusion

Delays in the prescription of fluids and analgesia are still present, with a proportion of patients not getting the appropriate treatment for acute pancreatitis. We will use a tailored prescription set for acute pancreatitis to ensure prompt prescriptions are done for patients. This will be re-evaluated to assess its effectiveness. Further evaluation is required to look at reasons for patients not getting cholecystectomy promptly after admission for acute pancreatitis.
HPB SO57 - Imaging in Acute Pancreatitis: Are We Getting It Right?
Authors: Pal Shreya , Oxenham Matthew , Allu Veera
Published: November 2024

Background

Guidelines indicate that routine use of imaging is unwarranted in patients with acute uncomplicated pancreatitis presenting with abdominal pain and increased serum amylase or lipase levels without signs of severe disease. Moreover, early CT scans may fail to accurately reflect disease severity and provide no diagnostic advantage.

Method

We performed a retrospective clinical audit at a district general hospital in the United Kingdom to find out the current practice regarding the use of imaging in patients presenting with acute pancreatitis. The patients were studied from January 2023 to March 2023 for the 1st cycle, and from April 2024 to May 2024 for the 2nd cycle. The list was identified by the clinical audit department – adult patients who presented to the A&E with symptoms of acute pancreatitis were included.

Results

Between January - March 2023, 44 patients presented to A&E with symptoms of acute pancreatitis. Of these, 25 (56%) had a CT-scan within 72-hours, with 80% showing evidence of acute pancreatitis —1 with pancreatic necrosis, 7 with intra-peritoneal fluid, & 5 with peri-pancreatic fat-stranding. The study revealed poor compliance with standards, prompting efforts to raise awareness. Findings were shared at the departmental audit meeting, & posters were displayed in A&E and GeneralSurgery departments. In the 2nd-cycle (April-May 2024), 32 patients presented, with 14 (53%) having a CT-scan within 72-hours & all had serum amylase levels checked, with 11 within normal limits.

Conclusion

This closed-loop clinical audit demonstrated that with appropriate measures and improved awareness of current guidelines, there can be increased compliance to the guidelines by the clinicians. This, in turn, reduces the risk of radiation exposure to patients and optimizes the use of CT scans.