bluuebunny/crossref_metadata_2025 huggingface dataset:
AHP SO03 - The role of the specialist upper gastrointestinal (UGI) benign dietitian in the management of benign UGI disorders – a review of the outpatient referral base
Authors: Jarvis Emma , Orla Evans
Published: November 2024

Background

Benign UGI disorders can negatively affect patients’ nutritional status by impacting on oral intake and/or through malabsorption. GSTT performs a high volume of benign UGI surgeries and is a tertiary referral centre for oesophageal reconstructions and complex hernias. The role of the dedicated specialist UGI benign dietitian was established in 2019 to provide dietetic expertise to the UGI multidisciplinary team (MDT). It supports patients before and after surgery with the aim of reducing post-operative complications, length of hospital stay, re-admissions and improving patient experience and quality of life.

Method

Outpatient referrals to the UGI benign dietetic service between 02/02/2024 and 06/06/2024 were reviewed for source of referral, reason for dietetic referral and UGI diagnosis.

Results

Twenty-five new referrals were received from a variety of clinical specialities (table 1). The primary UGI disorders of referrals are outlined in table 2, with complex hernia repair being the most common. Table 3 outlines the broad range referral reasons. Nutrition support referrals were received for the following disorders: achalasia, oesophageal stricture and following oesophageal perforation, hiatus hernia repair, cholecystectomy and oesophagectomy. All weight management referrals were for complex hernia repair patients. Referrals for the side-effects of UGI surgery included dietetic support with pancreatic exocrine insufficiency (pancreatectomy; distal gastrectomy), dumping syndrome (hiatus hernia repair) and delayed gastric emptying (oesophagectomy).

Conclusion

The role of the benign UGI dietitian requires skills and expertise in a broad range of dietetic interventions. The service is well utilised by surgical and non-surgical colleagues. Next steps for service development would be to review the impact of interventions on surgical and patient reported outcomes, and explore feasibility of patient groups to deliver dietetic advice (for example weight reduction prior to surgery) to improve capacity within the service.
EDI&S SO05 Barriers to delivering a net zero NHS: An evaluation of Sustainability in Surgery across the Midlands
Authors: Kanani Trisha , Al Saoudi Tareq , Holden Angela , Sharrod-Cole Hayley , Orrock Emma , Isherwood John , Dennison Ashley
Published: November 2024

Background

The healthcare sector is under increasing scrutiny for contributing approximately 4.6% of the UK’s total carbon footprint and 25% of the public sector’s carbon footprint. With support from the UK Health Alliance on Climate Change, the NHS aims to reach a net zero carbon target by 2045 through its Greener NHS campaign. This study aimed to identify key barriers to implementing sustainable practices in the surgical environment. It involved reviewing Green Plans published by Integrated Care Systems (ICSs) in the Midlands, conducting a thematic analysis of relevant literature, and surveying key stakeholders within NHS Trusts in the Midlands.

Method

Between June and September 2023, Green Plans from 11 ICSs across the Midlands were evaluated by two reviewers for the inclusion of the "key areas of focus" outlined by the NHS Green Plan Guidance. Additionally, three computerised searches were conducted using Ovid MEDLINE and Embase to retrieve abstracts published before May 2023 on reusable surgical gowns, re-sterilisation of surgical energy devices, and operating theatre waste management. Three reviewers screened the abstracts to identify barriers to implementing change. Based on these findings, a framework was developed for the “Supporting a Greener NHS Survey” and disseminated to key stakeholders in the Midlands.

Results

A heat map was created to assess compliance of each Green Plan with NHS England guidance (Figure 1). The literature search yielded 82 abstracts and key barriers to sustainability were identified as infection control, cost implications, instrument damage, and waste management practices. The survey received 89 responses; 45% did not use reusable drapes at their Trust, 35% did not use reusable gowns, 46% did not use reusable laparoscopic ports, and 59% didn’t know whether their energy devices were recyclable. Key barriers to implementing sustainable change included surgeon preference, financial constraints, and infection control concerns.

Conclusion

The literature analysis and survey of stakeholders in the Midlands identified several barriers to implementing sustainable changes. With national, regional and local organisational impetus coupled with clinical leadership commitment to sustainability, these barriers can be overcome with multi-disciplinary involvement. By investing in comprehensive training programmes and implementing rigorous quality control measures with input from infection prevention and control teams, clinical leaders and clinicians are best placed to help overcome these barriers and promote sustainability in the surgical environment.
BS SO07 - NHS Tertiary Centre Experience with Bariatric Tourism; A Call for National Registry
Authors: Alnagar Amr , Askar Mohab , White Emma , Wadley Martin , Robinson Steven , Perry Anthony , Noormohamed Mohamed Saleem
Published: November 2024

Background

Bariatric surgery has demonstrated notable efficacy and is becoming an increasingly popular practice. Nonetheless, patients often opt for bariatric tourism due to the unaffordability of bariatric procedures or the lengthy waiting lists. The postoperative care for such patients not only imposes financial burdens on a different health system, necessitating costly interventions for complex cases but also affects the allocation of resources for patients receiving care in the public health services. A national guidance platform and registry are required to measure the impact of bariatric tourism on the modern NHS and plan future resource allocation.

Method

This is a retrospective review of patients referred to one of the bariatric units in the United Kingdom for complications following bariatric procedures abroad. Patient demographics, bariatric intervention, presenting complications, length of hospital stay and management received were recorded.

Results

Between 2022 and 2024, our unit admitted nine patients. Eight had sleeve gastrectomy in Turkey, and one had a gastric balloon in Thailand. In the sleeve group, five patients had intractable vomiting, one had small bowel ischemia, one leaked, and one had reactive hypoglycemia. The patient with the gastric balloon had vomiting and abdominal pain, leading to balloon removal. Three sleeve patients had a conversion to Roux-en-Y bypass, one is under investigation, and one is awaiting bypass surgery, one required three surgeries for small bowel ischemia, and one with a leak was treated with a pigtail and gastric stent.

Conclusion

Medical tourism for bariatric procedures is an appealing option for obese patients due to its affordability and shorter wait times. Patients typically receive brief pre-operative preparation and education in addition to a limited post-operative care. However, managing complex bariatric cases is expensive, necessitates extended hospital stays and nutritional and emotional support, and can only be done in specialised centres. It's important to create a national bariatric surgery guidance platform providing recognised centre details internationally and a national registry of bariatric tourism patients to assess the impact on the healthcare system and to plan for future resource allocation.
BS SO12 - Long-term impacts of emergency presentations following bariatric health tourism on patients and health services: A UK perspective
Authors: Iqbal Mohd Javaid , Alabdellat Osama , Nimeh Baraa Abu , Alwani Omneya , Alkhaffaf Bilal
Published: November 2024

Background

Bariatric surgery is an effective treatment for obesity. Whilst short-term complication rates are low, little is known about the longer-term impacts on patients and health services. Even less is known about the true impact of the increasing trend of Health Tourism (HT) in this field. This study aimed to explore this topic further to quantify the impact of HT on UK healthcare services and to subsequently inform future service planning.

Method

This was a retrospective study of consecutive emergency inpatient episodes related to bariatric surgery (presenting to ED or transferred from other hospitals) at a regional bariatric centre. The study included patients between January 2018- April 2023. Data on index procedure (type, time to presentation, location), complications (and associated management), and subsequent readmissions, diagnostic investigations, and interventions (surgical, radiological, endoscopic) following first discharge from our centre was collected.

Results

308 patients (489 episodes) were included (188 patients had surgery in the UK, 77 HT, 43 unknown origin). Gastric band (50%) and gastric sleeve (39%) were the commonest causes for admission in UK and HT patients, respectively. 86 surgical interventions post discharge were required. An average of 2.0 diagnostic investigations were undertaken following discharge per patient (UK 2.3 vs HT 1.9). Following discharge, similar average rates of further readmissions (UK 0.6 v HT 0.6), surgical (UK 0.3 v HT 0.4), radiological (UK 0.2 v HT 0.2) and endoscopic interventions (UK 0.6 v HT 0.6) were seen between cohorts.

Conclusion

Patients presenting with emergencies following bariatric surgery require significant ongoing investigation and management following discharge from hospital. This ongoing burden is often overlooked in health services research. In our study, this demand was significantly increased by bariatric health tourism. This highlights the critical need to recognise this additional burden, improve service planning to accommodate increased service demand, and address underlying factors contributing to health tourism.
EGS SO04 - Gastrodoudenal Artery Pseudoaneurysm Secondary to blunt abdominal trauma: A rare case report
Authors: Mansour Mohamed , Thambi Prem , Fadhl Yousif
Published: November 2024

Background

Visceral artery pseudoaneurysms (VAPAs) are rare, potentially life-threatning aneurysms found in the celiac, superior, or inferior mesenteric arteries. They are most common in the splenic artery (60-70%), followed by hepatic arteries (20%) and celiac or mesenteric arteries (10%). Usually asymptomatic, VAPAs are often discovered incidentally during abdominal imaging. They pose a high risk of rupture and haemorrhage. Risk factors include iatrogenic injury and abdominal trauma. Traumatic VAPAs are extremely rare with unclear management guidelines. Treatment options vary from observation to endovascular therapy or surgical repair. This report presents a case of a gastoduodenal artery psuedoaneurysm due to blunt abdominal trauma.

Method

A case report: a 68-year-old male with a high BMI and atrial fibrillation managed with edoxaban, presented with severe upper abdominal pain following a fall. Initial examination and laboratory results suggested acute pancreatitis or cholecystitis, but a CT angiography revealed a GDA pseudoaneurysm with active extravasation. The patient was referred for urgent therapeutic embolization; however, the pseudoaneurysm had spontaneously thrombosed, precluding the need for embolization. The patient was managed conservatively, with close monitoring in the high dependency unit (HDU), analgesics, proton pump inhibitors, and mechanical venous thromboembolism prophylaxis. He remained hemodynamically stable and was discharged with instructions for follow-up care.

Results

GDA pseudoaneurysms are rare, accounting for 0.01-1% of all visceral artery aneurysms, with trauma being an exceptionally infrequent cause. The management of VAPAs, particularly in hemodynamically stable patients, can range from conservative observation to endovascular interventions. This case underscores the importance of a multidisciplinary approach involving surgery, interventional radiology, and vascular teams for optimal management.

Conclusion

Gastroduodenal artery pseudoaneurysms secondary to blunt abdominal trauma can be effectively managed conservatively in stable patients. Comprehensive history-taking, appropriate imaging, and multidisciplinary discussions are crucial for successful outcomes. Continued monitoring is essential to ensure patient safety and address potential complications.
EGS SO17 - Foreign body management - Time for improvement
Authors: Karagiannidis Georgios , Pervez Aneeka , Gunasekera Githmi , Sinclair Martin
Published: November 2024

Background

The management of foreign bodies (FBs) in clinical practice presents significant challenges across various medical specialties. FBs can be ingested, inhaled, inserted, or result from trauma, necessitating a comprehensive understanding of their management to prevent complications. The prevalence of FB incidents varies by age, with children being particularly susceptible to ingestion and inhalation, while adults often encounter FBs through trauma or occupational hazards. Effective management strategies are crucial to minimize morbidity and mortality associated with FB incidents.

Method

This study retrospectively reviewed cases of FB management over eight years (2015-2023), encompassing various specialties including gastroenterology, upper gastrointestinal and colorectal surgery. Data were collected on patient demographics, type and location of FB, method of removal, complications, and outcomes. Imaging techniques, such as X-rays, CT scans, and endoscopic evaluations, were analysed for their efficacy in FB detection. Different removal techniques, including endoscopic, surgical, and non-invasive methods, were evaluated for success rates and associated complications.

Results

Of the 153 FB incidents,47% involved male patients and 53% involved female patients.The paediatric group accounted for 36% of incidents.Non-invasive management was successful in 62% of cases,while 37% required invasive procedures.Among invasive interventions,70% required operative intervention,10% endoscopic intervention and 20% other minimally invasive options.The time to intervention for invasive procedures varied with more than 50% taking place after 24 hours.For operative interventions,64% occurred over 24 hours after presentation,21% within less than 24 hours, and 14% within 12 hours.All endoscopic interventions were performed within 12 hours.Outcomes showed that 96% of cases were managed without further complications.There were no reported mortalities.

Conclusion

Effective management of FBs requires a timely and appropriate intervention strategy tailored to the patient’s age and the type of FB. Non-invasive methods successfully managed most cases, while invasive procedures were necessary for a significant proportion. Prompt intervention, particularly endoscopic and other minimally invasive techniques, was associated with favorable outcomes and minimal complications. No mortalities were reported, underscoring the efficacy of current management protocols. Further research is needed to optimize these protocols and improve outcomes across diverse patient populations.
OGC SO01 - Patients undergoing major upper gastrointestinal resection admitted to an enhanced peri-operative care facility: Two years of outcomes
Authors: Schofield Matthew , Hackett Stephen
Published: November 2024

Background

The Author's Trust has set up an Enhanced Peri-Operative Care facility (EPOC) to provide a higher level of monitoring in the immediate postoperative period, for certain patients undergoing elective major surgical procedures. Patients receive a nursing ratio of 2:1, invasive blood pressure monitoring, and epidural and peripheral vasopressor infusions if required, for one day before being discharged to the ward. This service, in carefully selected patients, can remove the need for critical care admission, which patients undergoing major upper gastrointestinal (UGI) resection previously required. We believe this to be a novel pathway in the UK for major UGI resections.

Method

Between November 2021 to November 2023, 170 major UGI resections (oesophagectomies and gastrectomies [including total and subtotal]) were performed. 82 of these cases (48%) were admitted to EPOC, instead of the Critical Care Department (CCD). The primary project outcome consisted of the proportion of EPOC cases being successfully discharged to the ward by the end of day one. Patients failing to meet the requirements for safe EPOC discharge were transferred to the CCD. Secondary outcomes included total admission length, need for escalation to critical care after discharge from EPOC and patient deaths.

Results

78% of cases admitted to EPOC after major UGI resection were able to be discharged to the ward by the end of day one. The total admission length of these cases was 11.5 days. 4.6% of patients discharged to the ward from EPOC later developed complications and needed to be transferred to the CCD. 96% of patients were discharged home. Three patients died.

Conclusion

The Trust has been sending major UGI resection cases to EPOC for over two years. This is the first project looking at the combined outcomes. The first year was audited in 2022 and results were used to support pathway expansion, with an increased number of patients admitted in year two. The results support the notion that when patients are selected correctly they can be cared for safely in an EPOC setting, relieving pressure on the CCD and reducing the likelihood of cancellation due to critical care capacity, improving the efficiency of the UGI surgical service.
OGC SO11 - Impact Evaluation of Endoscopic Mucosal Resection in the Foregut in a Tertiary Centre in the United Kingdom (UK)
Authors: Kwan Yi Xin , Pua Qiao Ying , Loh Danielle , Viswanath Y K S
Published: November 2024

Background

Endoscopic mucosal resection (EMR) has emerged as a crucial technique for managing early-stage lesions in the oesophagus and stomach, encompassing precancerous and cancerous conditions.1 With fewer complications and excellent 5-year survival rates, EMR has shown potential as a less-invasive alternative to surgical resections.1 EMR achieves higher accuracy with its ability to obtain more profound and better quality tissue samples compared to conventional biopsies, which facilitates multidisciplinary team (MDT) discussions regarding treatment decisions.1 This study aims to evaluate the impact of EMR performed in an Oesophago-Gastric Cancer tertiary centre in the UK.

Method

This is a retrospective service evaluation of patients who underwent EMR from March 2021 to March 2024. A sample size of 73 EM (n=73) is identified. Data were collected from medical and endoscopic records, which includes patient’s demographics, American Society of Anaesthesiologists (ASA) grade, EMR indication, histology report and MDT outcome. EMRs performed were categorised into oesophageal, gastric and duodenal. Three main referral indications were identified; ‘polyp’, ‘dysplastic nodule in Barrett’s oesophagus’ and ‘possible early malignancy’. MDT outcomes were analysed thematically.

Results

Of the seventy-three patients identified, 78% is male and mean age at 71 years. Most patients (81%) are classified as ASA Grade 2. Polyp is identified in 37 patients (51%), making up the most common referral indication. 49% of the EMR were gastric, with remaining being oesophageal (41%) and duodenal (11%). 26% of histology results showed benign disease, 40% dysplastic disease, and 34% malignant. From histology reports, 47% of the EMRs achieved complete clearance margins. 28 patients (38%) were discharged with no further interventions and 12 patients (16%) received repeat EMR. 4 main themes were identified from MDT outcomes, with 43.8% patients needing surveillance endoscopy, 16.7% patients recommended for surgical intervention and repeated EMR each.

Conclusion

EMR has shown to be effective as a reference for further treatment decisions, especially for MDT discussions. It has been proven that EMR can be therapeutic in providing complete resection, particularly for benign and early dysplastic diseases.
OGC SO14 - Management of Anastomotic Leaks after oesophagectomy for oesophageal cancer in the era of Endoscopic Vacuum Therapy
Authors: Peristeri Dimitra , Ibrahim Ahmed , Powell Arfon , Farooq Naheed , Alkhaffaf Bilal
Published: November 2024

Background

Anastomotic leak (AL) is a serious complication following oesophagectomy that occurs in 10-15% of patients. Endoscopic vacuum therapy (EVT) is a novel non-operative approach to managing AL that has become increasingly popular recently. However, little is known about EVT’s effectiveness in managing ALs compared to more established approaches.

Method

This was a retrospective review of consecutive AL management in a regional oesophageal cancer centre during two distinct time periods: prior to (group 1, 2014-2018) and following (group 2, 2018-2023) the introduction of EVT. 66 patients met the inclusion criteria. Patients were further classified according to size and type of leak, degree of mediastinal soiling and degree of sepsis. Primary endpoints were treatment success, 90-day mortality, and long-term preservation of gastrointestinal continuity. Secondary endpoints were the length of hospital stay (LOS) and re-interventions during the first postoperative year.

Results

80.3% of patients (14 in group 1, 40 in group 2) had less than 1cm AL defect with present sepsis and a small mediastinal cavity. In group 1, 12 were treated successfully conservatively, and 2 (14.2%) had T-tube insertion. In group 2, 20 (50%) had conservative management and 19 (47.5%) had Esosponge insertion. The success rate was 95% and 94.7%, respectively. In bigger ALs (>1cm defect with severe sepsis), all patients in group I were treated with thoracotomy with a success rate of 75%, whereas in group 2, 60% were treated with Esosponge insertion with a success rate of 83.3%.

Conclusion

EVT is a safe and feasible therapy option. It appears to improve outcomes in septic patients with small ALs and potentially reduces the need for high-risk revisional operations.
OGC SO20 - Audit of the guidelines for staging laparoscopy in gastro-oesophageal cancers
Authors: Penny Nancy , Saunders John
Published: November 2024

Background

Staging laparoscopy and peritoneal washings form part of surgical work up of oesopheageal and gastric cancers. Peritoneal washings help to identify microscopic disease, the presence of which drastically alters prognosis. This audit looks at the adherence to staging laparoscopy guidelines introduced, and the intraoperative finding.

Method

Staging laparoscopy and peritoneal washings form part of surgical work up of oesophageal and gastric cancers. Peritoneal washings help to identify microscopic disease, the presence of which drastically alters prognosis. This audit looks at the adherence to staging laparoscopy guidelines introduced, and the intraoperative finding.

Results

Two hundred and twenty-seven patients were identified. Two patients did not have washings performed due to the extent of their disease, which was appropriate. The remaining patients had washings performed. Twelve patients had washings performed but not in line with policy. In all cases a clinical reason was found. Overall twelve patients had positive cytology from the washings. Of those that had washings, forty-one patient’s had T1/T2 disease and one hundred and eight-four patients had T3/T4 disease. All cytology positive patients had T3/T4 stage disease.

Conclusion

Two hundred and twenty-seven patients were identified. Two patients did not have washings performed due to the extent of their disease, which was appropriate. The remaining patients had washings performed. Twelve patients had washings performed but not in line with policy. In all cases a clinical reason was found. Overall twelve patients had positive cytology from the washings. Of those that had washings, forty-one patient’s had T1/T2 disease and one hundred and eight-four patients had T3/T4 disease. All cytology positive patients had T3/T4 stage disease
OGC SO44 - Robotic gastric resection is feasible and safe - the first 25 cases at a tertiary UK Oesophago-gastric unit
Authors: Cross Andrea , Brown Joshua , Phillips Alexander , Wahed Shajahan , Immanuel Arul
Published: November 2024

Background

Robotic approaches to upper GI surgery are being increasingly used due to purported benefits including improved vision and dexterity over conventional laparoscopy, and reduction in surgical trauma and wound-related morbidity over open surgery. Introduction of new technology and its implementation into practice comes with an inevitable learning curve and it is paramount that this does not occur at the expense of patient outcomes. This study looked at the surgical and oncological outcomes from the implementation of a robotic gastric resectional service at a tertiary centre in the UK.

Method

A prospectively maintained database was used to identify all patients undergoing robotic subtotal and total gastrectomy irrespective of indication. Patients having sleeve gastrectomy or gastric wedge resection were not included. Demographic, operative, pathological and complications data were included. Complications were graded using the Clavien-Dindo classification. Textbook outcomes for gastric cancer surgery were defined as complete resection, pathological R0, >15 lymph nodes resected, no intraoperative complications, no reintervention, no ICU readmission, no prolonged hospital stay (defined as > 21 days), no mortality or readmission at 30 days, and no severe complications (Clavien Dindo ≥ II).

Results

Twenty-five patients were identified, 13 (52%) were women and the median age was 73 (range: 40 – 88). Twenty-two (92%) had a subtotal gastrectomy and adenocarcinoma was the diagnosis in 15 (62.5%).

Median blood loss was 50ml (50 – 310 ml) and operative time 320 minutes (225 – 480 minutes). There were no conversions to open. Complications occurred in 6 (24%) with one leak, 2 theatre returns, one death and no readmissions. Median stay was 6 days (4-14 days). Of the 16 having cancer surgery, median nodal yield was 29.5 (16 – 66), R0 rate 100% and a textbook outcome achieved in 14 (87.5%).

Conclusion

Robotically-assisted gastric resection can be implemented with a low rate of complication. In those patients having surgery for cancer, pathological outcomes were good and 14/16 patients achieved a textbook outcome which is significantly higher than most published studies.
BN SO11 - Optimising Day Case Laparoscopic Cholecystectomy: A GIRFT-Based Audit and Efficiency Analysis
Authors: MacDonald-Nethercott Meiling , Jacob Preethi , Tanner Nicola , Finch Guy
Published: November 2024

Background

Laparoscopic cholecystectomy (LC) is the gold standard for managing symptomatic gallstone disease and is commonly performed as a day surgery procedure due to its safety and efficiency. Despite its established benefits, recent analyses at our local hospital revealed a decline in the day case rate for elective LC, falling below the national median as highlighted by the Get It Right First Time (GIRFT) data.

Method

We analysed patient data for elective LC performed between 1st October 2023 and 29th February 2024. The data included patient demographics, length of stay, and reasons for unplanned admissions. Procedures from the hot and emergency lists were excluded from the analysis. To enhance the day case rate, a business case was developed to extend recovery staffing levels and coverage hours in the DSU from 6pm to 9pm. Additionally, we requested the coding team to distinguish elective cases from hot list cases for more accurate future analyses. The impact of these changes will be evaluated in a subsequent audit cycle.

Results

During the observed period, 86 elective LC cases were performed, with a day case rate of 64% (55/86), exceeding the national median of 60%. The discrepancy with the GIRFT analysis was due to the inclusion of hot list cases in their data. The primary reasons for unplanned admissions included monitoring observations (46%), late afternoon extubations (29%), and intra-operative concerns (18%). The median length of stay for unsuccessful day cases was 1 day. Cost analysis estimated the unplanned admission costs at over £12,000 for LC alone during the observed period, based on the NHS National Tariff 2024/25.

Conclusion

This audit demonstrated that our day case rate for elective LC surpasses the national median. By identifying key factors leading to unplanned admissions, we implemented targeted interventions, such as extending recovery area hours. These measures aim to further improve the day case rate, enhance patient care, and achieve significant cost savings.
BN SO12 - Management Strategies for Complications in Common Bile Duct Exploration: A Single Unit Comprehensive Analysis
Authors: Salem Rola , Hale Emily , Poulton Theodore , Bush Alexander , Kostalas Marcos
Published: November 2024

Background

10-20% of individuals with systemic gallstones are estimated to have common bile duct stones (CBDS)(1). Laparoscopic common bile duct exploration (LCBDE) and two stage laparoscopic cholecystectomy (LC) with subsequent endoscopic retrograde cholangiopancreatography (ERCP) are clinically equivalent in their purpose but associated with different risks and require different skill sets, training and facilities. This study has retrospectively reviewed all LCBDE in our Benign Upper Gastrointestinal Surgery Unit, in particular analysing complications, the management strategies employed, and the impact associated with these interventions.

Method

A retrospective analysis was conducted on all patients (n=427) who underwent LCBDE between November 2013 and May 2024 at our benign Upper Gastrointestinal Surgery Department to evaluate complications. Comparison is made with British Benign Upper Gastrointestinal Surgical Society (BBUGSS) standards.

Results

16.6% (n=71) experienced complications; 3.28% (n=14) retained stone, 3.74% (n=16) bile leak, 9.6% (n=41) non-specific surgical complications.

Bile leak approaches were transcystic (n=2), transcystic converted to cholecdochotomy (n= 3), and choledochotomy n=11. Leaks were diagnosed on ERCP (50%), drains (n=3), CT (n=4) and clinical suspicion (n=1). 50% (n=8) were managed by ERCP, n=6 laparoscopic washout, and n=2 conservatively.

Of retained stones, n=5 were indicated intraoperatively, n=7 on readmission with pain, n=1 on tubogram, and n=1 due to increased drain output. 80% (n=12) managed via ERCP with sphincterotomy +/- stenting. Of the remainder n=1 underwent open exploration, and n=1 managed conservatively.

Conclusion

Bile duct complications can be life altering and thus early identification and management is paramount. BBUGSS’ recommended performance standards for LCBDE state that frequency of retained stones should be <15%, bile leaks <5% and return to theatre <5% (2). In our trust rates are 3.51%, 3.74% and 1.64% respectively. Our stone clearance rate is 96.49%, higher than the BBUGSS standard of >85% (2). Our findings conclude that a benign UGI unit in a District General Hospital can deliver a one stage approach with good management of complications from LCBDE.
BN SO13 - Re-Audit of Biliary Pancreatitis Management: Enhancing Compliance with Timely Laparoscopic Cholecystectomy
Authors: Sakr Mohamed , Methany Reda
Published: November 2024

Background

Biliary acute pancreatitis requires timely management to prevent complications. Guidelines recommend laparoscopic cholecystectomy within two weeks of admission. A previous audit in our surgery department showed only 32.6% compliance with this guideline. This re-audit aimed to evaluate improvements in compliance, identify barriers, and provide insights for enhancing patient care. By retrospectively analyzing patient data from January to November 2023, we assessed progress and highlighted areas needing further improvement to align with established guidelines and ensure better patient outcomes.

Method

A retrospective analysis was conducted on a cohort of 32 patients admitted to the general surgery department with a diagnosis of biliary acute pancreatitis between January 2023 and November 2023. Patient records were reviewed to gather data on the timing of laparoscopic cholecystectomy performed within two weeks of the index admission. The compliance rate from this period was compared to a previous audit to assess improvements. Key barriers to timely intervention, such as the availability of ultrasound slots, hot gallbladder lists, and pre-assessment clinics, were also identified and analyzed. Statistical methods were used to confirm the significance of observed changes.

Results

he re-audit revealed a significant improvement in compliance with guidelines for the management of biliary acute pancreatitis. The percentage of patients undergoing laparoscopic cholecystectomy within two weeks of admission increased from 32.6% in the initial audit to 64.5% in the re-audit. However, the analysis identified persistent barriers to timely intervention, including limited availability of ultrasound slots, insufficient "hot gallbladder" surgical lists, and fear of difficulty of acute laparoscopic cholecystectomy. These findings highlight both the progress made and the areas needing further attention to enhance compliance and patient care.

Conclusion

The re-audit demonstrated a notable improvement in adherence to guidelines for the management of biliary acute pancreatitis, with a significant increase in timely laparoscopic cholecystectomy. Despite this progress, persistent barriers such as limited ultrasound availability, insufficient "hot gallbladder" lists, and pre-assessment clinics need to be addressed. Continuous evaluation and targeted interventions are essential to further enhance compliance, reduce complications, and improve patient outcomes. Ongoing efforts to refine clinical practices will help achieve the highest standards of care for patients with biliary pancreatitis.
BN SO16 - Gastro-gastric intussusception without any lead point – a case report and review of literature
Authors: Ngo Vivien , D’Souza Joel , Scott Harriet , Howes Nathan
Published: November 2024

Background

Gastrogastric intussusception in a rare condition in adults. The underlying aetiologies include pathological lead points, anatomical abnormalities, previous foregut surgery or foreign body. The management of symptomatic gastrogastric intussusception in the absence of these aetiologies remains poorly defined and is highlighted by the paucity of evidence available for guidance. We present a case of idiopathic gastrogastric intussusception and a review of the literature.

Method

A 34-year-old male patient with a background of thrombocytopenia-absent radius (TAR) syndrome presented with recurrent episodes of upper abdominal pain and vomiting. Investigations with a CT abdomen revealed proximal gastrogastric intussusception. Subsequent endoscopy showed oedematous mucosa along the lesser curve and no pathological lead points or anatomical abnormalities. Histological findings were normal.

Results

The patient remained symptomatic despite a normal subsequent CT abdomen. A consensus decision was reached, and the patient was counselled for a laparoscopic gastropexy. Laparoscopic findings showed a central area of scar tissue circumferentially along the mid-body of the stomach highlighting the chronicity of the condition. No hiatal abnormalities were identified. A gastropexy was performed in two layers along the greater curvature of the stomach with non-absorbable interrupted sutures. The postoperative course was unremarkable. The patient remained asymptomatic on 6-week clinic follow up.

Conclusion

No previous case reports of idiopathic gastrogastric intussusception were identified on our literature search. It is our impression that this is the first such case-report to illustrate the diagnostic challenges of this rare, intermittently symptomatic condition and the successful management of it.
BN SO20 - Day-case laparoscopic cholecystectomy: Predictors of failure
Authors: Marks Bertram , Sow Karmen , Owen Lucy , Haddington-Ahmed Aysha , Carr William
Published: November 2024

Background

Laparoscopic Cholecystectomy (LC) is the main treatment option for symptomatic gallstone disease. It is commonly performed as a day case operation and Getting It Right First Time (GIRFT) have suggested that this should be the default position for all trusts. NHSE Model Hospital analyses hospital metrics and sets national benchmarks. They suggest that the day case rate for LC should be greater than 71.4%. The aim of our study is to analyse all elective LC’s over a two year period and identify factors that increase the likelihood of day-case failure and the common reasons for this.

Method

All patients who had LC between 1st July 2020 and 30th June 2022 were identified. All emergency cholecystectomies were excluded from analysis. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Statistical analysis was performed using SPSS with Chi-squared tests performed for categorical data and ANOVA for continuous data. Odds ratios with 95% confidence intervals were calculated. Statistical significance was taken as p<0.05.

Results

788 patients had elective cholecystectomies with 74.0% being successful day-case. Factors increasing day-case failure included: Admission with gallbladder disease within past year (OR 3.15 (2.26-4.37), CBD diameter>8mm (OR 2.17(1.44-3.26), thick-walled gallbladder (OR 2.20(1.59-3.04), on-table cholangiogram (OR 4.16 (2.21-7.84), sub-total cholecystectomy (OR 30.6(9.19-102) and male sex (OR 1.55(1.11-2.18). Patients who failed day-case had higher mean age (59 vs 49) and higher co-morbidity index (2.16 vs 1.44). The most common reasons for day-case failure were complex procedure (41%), and symptom control (35%). Only 20% had planned admissions. 30-day morbidity and re-admission rate were higher for failed day-case patients.

Conclusion

Our hospital complies with the day case benchmark set out by Model Hospital. Furthermore, only 5.2% of patients undergoing elective cholecystectomy had a pre-operative decision for an inpatient stay demonstrating that day case is the default for the vast majority of patients. Despite this, improvement could still be made with post-operative symptom control to try and increase this number further.
BN SO28 - Dual Mesh Technique in Revisional Complex Laparoscopic Repair of Recurrent Paraesophageal Hernia (PEH)
Authors: Kwan Yi Xin , Pua Qiao Ying , Loh Danielle , Viswanath Y K S
Published: November 2024

Background

Mesh Augmentation in laparoscopic repair of complex PEH has been an ongoing debate with regards to its risk profile and success rate in reducing hernia recurrence.1 There have been concerns regarding the deployment of non-absorbable mesh around the hiatus resulting in erosion and stricture, which may lead to oesophagectomy or gastrectomy.2 Absorbable mesh has been introduced with appealing advantages of lower mesh-related morbidities, however its high cost and unclear long-term durability remains questionable for its role as an ideal mesh.2

Method

This is the case of a 65-year-old patient with chronic reflux symptoms undergoing revisional complex laparoscopic repair of recurrent type 4 PEH. The focus of this video is using a dual mesh technique involving fixation of a non-absorbable synthetic mesh at least 15mm from the oesophageal wall, reinforced with placement of an absorbable biosynthetic mesh which is in contact with the hiatus boundary.

Results

With regards to position of the permanent synthetic mesh, direct contact with the oesophagogastric wall should be avoided due to complications secondary to erosions and strictures. The deployment of a second mesh of absorbable material is preferred in this patient for hiatal reinforcement to reduce risk of recurrence due to friability of adjacent tissues.

Conclusion

The dual mesh technique aims to overcome the limitations of both types of mesh materials while preserving their individual benefits, expectantly reducing recurrence.
BN SO36 - Robotic versus laparoscopic giant hiatus hernia repair - is one superior in clinical outcomes?
Authors: Sinha Yashashwi , Howey Caitlin , Paz Betheliza Dela , Fernando Tyrrel , Akbari Khalid , Tan Lam Chin , Menon Vinod , McLaughlin Euan
Published: November 2024

Background

The number of robotic giant hiatal hernia repair (RGHHR) procedures is steadily increasing. RGHHR offers several potential advantages over traditional laparoscopy, including enhanced visualisation, superior ergonomics, and the use of articulating instruments, which can be particularly beneficial in the restrictive operating field of the diaphragmatic hiatus. However, the outcomes of RGHHR remain heterogeneous, both when reported alone and in comparison to laparoscopic giant hiatus hernia repair (LGHHR). This study aims to evaluate and compare the key clinical outcomes of RGHHR and LGHHR in adult patients.

Method

All patients undergoing primary giant hiatus hernia (GHH) surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document: patient demographics, hernia type, operative details. Use of mesh and gastropexy (as proxy measures to indicate difficulty of operation). Follow-up duration in weeks. Open cases within this cohort were excluded.

Outcomes were: length of stay (LOS), 30-day morbidity measured using Clavien-Dindo (CD) grading, RTT and 30-day mortality. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant.

Results

Table 1. Patients LGHHR RGHHR p n 56 29 Age (median) 71 (31-93) 66 (39-85) 0.1303 Female (%) 68.7 70 0.8988 BMI 31.8 (±6.4) 29.9 (±3.4) 0.1715 ASA grade (average) 2.4 2.2 0.0587 Hernia Types (median) 3 3 0.4411 Median follow-up (weeks) 8 (1-161) 12 (3-172) 0.5763 Table 2. Operative details LGHHR RGHHR p Mesh used (%) 9.1 0 0.0907 Gastropexy (%) 12.7 6.9 0.4175 Table 3. Outcomes LGHHR RGHHR p LOS (median) 1 (0-161) 2 (0-15) 0.4177 30-day morbidity (CD≥3, %) 3.6 6.9 0.9193 RTT (%) 9.1 6.9 0.5570 30-day mortality 0 0 NA

Conclusion

RGHHR approach has been successful in managing complex GHH, with low RTT, low co-morbidity and no mortality. In our institution RGHHR has demonstrated non-inferiority to LGHHR in respect to clinical outcomes. Patient factors and hernia types did not affect case selection.

Use of mesh and gastropexy showed no difference in outcomes between the two groups. Cost, operative time and surgeon strain/fatigue were not evaluated in this study, however, these would provide useful additional comparative markers for the future.
BN SO38 - Bile Duct Injuries Referrals and Management in a Tertiary Centre in UK– A 6-year study
Authors: Cardoso Swizel Ann , Neophytou Christodoulos , Mukadam Alifya , Kazi Saad , Bartlett David
Published: November 2024

Background

Laparoscopic Cholecystectomy (LC) is the standard treatment for symptomatic cholelithiasis. It has been associated with serious complications, such as vascular/biliary injuries (0.4-0.7% of cases) requiring surgical, endoscopic or radiological interventions.

Objective

To evaluate the management, intervention and outcomes post bile duct injuries (BDI)

Methods

We conducted a retrospective analysis on all patients referred with BDIs from regional centres, following a planned LC operation and treated at the HPB unit of Queen Elizabeth Hospital Birmingham between 2018 - 2023. Patients were followed up for at least one year.

Results

In our unit, 22 (12 male) patients, with a median age of 60 years (16-85) were treated, primarily for gallstone disease (n=14). Most sustained grade E injury (n=19) and were recognised and transferred on average in 4 days (0-43 days). 20 patients had a hepaticojejunostomy. Using the Clavien-Dindo classification, three patients had grade III complications requiring intervention, and one had grade IV complication with sepsis and cardiac failure, necessitating ITU transfer for inotropic support. Discharge occurred within 10 days (4-96), with follow-up over 18.8 months (5-65). Seven await further follow-up, six were discharged and two await PTC for anastomotic stricture.

Conclusion

Our cohort underscores the complexity and critical nature of these injuries. Most patients required hepaticojejunostomy, with a median recognition and transfer of four days. While the early discharge and follow-up outcomes are promising, ongoing monitoring is essential, as patients might commonly develop anastomotic strictures, requiring conservative, radiological or surgical management. These findings highlight the necessity for prompt recognition and referral to specialised HPB units to optimise patient outcomes and reduce the long-term complications associated with BDIs.
BN SO39 - Laparoscopic Release of Median Arcuate Ligament Syndrome: A Case Series
Authors: Patel Agastya , Lancellotti Francesco , Lambert Joel , Kadamapuzha Jacob , Satyadas Thomas
Published: November 2024

Background

Median arcuate ligament syndrome (MALS) is a recognized, but rare condition, which is characterized by compression of the celiac artery and ganglion by median arcuate ligament. The entity often presented with chronic post-prandial abdominal pain, vomiting, and weight loss. These patients often undergo comprehensive investigation prior to diagnosis of MALS. This report presents our experience and short-term outcomes of patients with laparoscopic release of MALS at our center.

Method

Between 2022-2024, five patients with MALS underwent laparoscopic release at a tertiary HPB center under a single surgeon (TS). Data on patient demographics, presenting symptoms and duration, preoperative diagnostic tests, intraoperative findings and complications, postoperative complications, symptom recurrence and follow-up were prospectively maintained. All patients were discussed at a tertiary Vascular and HPB MDT; MALS was confirmed on US doppler (USD) and CT angiogram (CTA) (fish-hook type configuration of Celiac Truck with post-stenotic dilatation).

Results

Two male and three female patients, with a median (range) age of 41 (25-70) years, underwent laparoscopic MALS release. The median (range) preoperative symptom duration was 54 (24-67) months, with most common presentation of post-prandial abdominal pain and weight loss. The median (range) BMI was 19.61 (18.30-17.82). The median (range) operative time was 313 (166-330) minutes. One patient required conversion to open due to bleeding from celiac trunk. The median (range) LOS was 7 (4-7) days. No postoperative complications occurred. The median follow-up was 10 months. One patient re-experienced abdominal pain, with no evidence of recurrence on USD and CTA.

Conclusion

Median Arcuate Ligament Syndrome should be considered as a differential in patients presenting with chronic post-prandial abdominal pain and weight loss. Thorough investigation (USD and CTA) along with discussion at Vascular MDT should be undertaken. Laparoscopic release of MALS is a safe and effective treatment option in this cohort.