bluuebunny/crossref_metadata_2025 huggingface dataset:
O-L05 Do Subsets of Patients with Intrahepatic Cholangiocarcinoma and Combined Hepatocellular-Cholangiocarcinoma Benefit from Transplantation? A Systematic Review, Proportional Meta-Analysis and Meta-Regression
Authors: Cambridge William , Drake Thomas , Fairfield Cameron , Guest Rachel
Published: December 2021

Background

Resection remains the main curative treatment option for intrahepatic cholangiocarcinoma (iCCA) and combined hepatocellular-cholangiocarcinoma (cHCC-CCA), however, outcomes are poor. Recent retrospective analyses of patients found to have incidental iCCA and cHCC-CCA following transplantation have suggested that transplantation may be superior to resection. We performed a systematic review and proportional meta-analysis to estimate the benefit of transplantation for iCCA and cHCC-CCA.

Methods

MEDLINE, EMBASE, Scopus, and Web of Science were searched from January 1990 to December 2020. All studies reporting patients with iCCA and cHCC-CCA undergoing transplantation were identified. A proportional meta-analysis was performed, pooling overall survival (OS), disease-free survival (DFS), and recurrence rates post-transplantation. Sub-group analyses were performed for patients with ‘early’ iCCA, ‘advanced’ iCCA, Goodman type I cHCC-CCA, and Goodman type II cHCC-CCA. Univariable meta-regression was completed assessing the impact of variables reported by at least five studies on OS and DFS at 5-years, as well as recurrence post-transplant.

Results

Twenty-eight studies including 489 patients were identified (249 with iCCA and 240 with cHCC-CCA). Pooled OS and DFS at 5-years were lower in the iCCA group, 30.2% (95% CI 18.6% – 43.1%) and 29.2% (95% CI 20.4% – 38.9%), compared to the cHCC-CCA group, 55.0% (95% CI 47.2% – 62.8%) and 43.2% (95% CI 30.2% – 56.7%). In the ‘early’ iCCA group, pooled OS at 5-years was 66.5% (95% CI 47.2% – 83.3%). When separated by Goodman type, those with type II tumours reported higher pooled OS, 69.7% (95% CI 57.8% – 80.5%), compared to type I tumours, 61.3% (95% CI 46.1 – 75.5). Univariable meta-regression found only microvascular invasion impacted overall survival at 5-years and recurrence following transplantation in the iCCA group. At 5-years there was a negative correlation between the proportion of patients found to have microvascular invasion and overall survival (Adjusted R2 = 0.89, p = 0.017). There was a positive correlation between the proportion of patients with microvascular invasion on explant pathology and recurrence following transplantation (Adjusted R2 = 0.76, p = 0.047).

Conclusions

Subsets of patients with iCCA and cHCC-CCA may benefit from liver transplantation. However, further research, including clinical trials exploring transplantation in 'early' disease and in comparison to resection, is required to conclude which subsets of patients will benefit most from transplantation.
O-L08 Prognostic value of body morphometrics in patients undergoing surgery for hilar cholangiocarcinoma
Authors: Gilbert Timothy , Quinn Marc , Bird Nick , Diaz-Nieto Rafael , Jones Robert , Fenwick Steven , Malik Hassan , Gordon-Weeks Alex
Published: December 2021

Background

Hilar cholangiocarcinoma is an aggressive cancer with poor prognosis. Complex pre-operative workup is required prior to major surgery that frequently involves an extended hepatectomy with biliary reconstruction and is associated with high levels of post-operative morbidity and mortality. Tools to predict overall and disease-specific outcome are required to better tailor pre-habilitation interventions and selection of patients for surgery. Here we investigate whether body morphometrics are associated with disease-free and overall survival.

Methods

Consecutive patients undergoing resection of hilar cholangiocarcinoma were identified within a prospectively maintained database in a single institution. The CoreSlicer web-based app was used to calculate body morphometrics at the L3 vertebral level (muscle, visceral and subcutaneous fat areas) from portal-phase CT images. Median cut-offs defined patient groups and height-normalised morphometric values were compared at diagnostic and subsequent pre-operative imaging. Multivariate analysis was used to identify relationships between body morphometrics at time of diagnosis, changes in body morphometrics in the pre-operative period and outcome.

Results

Body morphometrics were assessed in 88 patients at the time of diagnosis. Of these patients, 53 underwent re-staging enabling an assessment of change in body morphometrics during the pre-operative period. Men displayed significantly higher muscle area, visceral fat and lower subcutaneous fat than women. High visceral fat area at diagnosis was an independent predictor of reduced overall survival (HR 1.81, 95% CI 1.1-3.3, P = 0.03), whilst loss of skeletal muscle area during the pre-operative period was an independent predictor of reduced disease-free survival (HR 2.90, 95% CI 1.0-8.8, P = 0.05). Patients with higher visceral fat at diagnosis also appear at increased risk of post-hepatectomy liver failure (PHLF) and experience significantly higher 30-day mortality than those without elevated visceral fat.

Conclusions

The presented results identify potential value in assessing body morphometrics as a prognostic tool in patients undergoing surgery for hilar cholangiocarcinoma. External validation of these findings in larger patient cohorts will help to determine whether this can be utilised to guide pre-habilitation interventions and appropriately select patients for surgery.
O-OGC02 Stage Migration in Newly Diagnosed Oesophago-gastric Cancer during the first wave of COVID-19 Pandemic
Authors: Khan Khurram , Gall Lewis , Chuntamongkol Rongkagorn , McCollum Catherine , Dreyer Stephan , Craig Carol , MacKay Colin , Macdonald Andrew , Forshaw Matthew
Published: December 2021

Background

Covid-19 has significantly disrupted elective and emergency health care provision including cancer care within the UK. The aim of the study was to investigate the impact of the pandemic on the staging of oesophago-gastric cancers at presentation, determine the time delay in performing gastroscopy and the multidisciplinary team (MDT) treatment outcomes.

Methods

A retrospective cohort study of all newly diagnosed oesophago-gastric cancers (adenocarcinoma and squamous cell carcinoma) in a single regional MDT was performed between 1st October 2019 and 30th September 2020. Electronic records were interrogated and patients dichotomised into two groups with those presenting before the introduction of the UK national lockdown of 23rd March 2020 compared to those presenting post-lockdown.

Results

349 new oesophago-gastric cancer patients were discussed in the MDT (192 pre-lockdown versus 157 post-lockdown). Demographics were evenly matched between the two groups. More patients presented as an emergency admission post-lockdown (28.0% vs 12.5%, p < 0.001). Median waiting time for gastroscopy was longer post-lockdown (23 vs 14 days, p = 0.035). Metastatic disease at presentation was more frequent post-lockdown (47.8% vs 33.3%, p = 0.008). Overall, more patients had a palliative rather than curative treatment intent post-lockdown (71.3% vs 57.8%, p = 0.005).

Conclusions

The Covid-19 pandemic has had a significant negative effect on the stage of oesophago-gastric cancers at presentation. This has translated into more patients receiving palliative treatment and ultimately having a poorer prognosis. This study highlights the importance of maintaining cancer services during the Covid-19 pandemic.
O-OGC09 PD-1 inhibitors in Oesophageal Cancer: A systematic review of the oncological outcomes associated with PD-1 blockade and the evolving therapeutic landscape
Authors: Whooley Jack , Azzawi Muhammed Al , Donlon Noel , Bolger Jarlath , Robb William
Published: December 2021

Background

Patients with oesophageal or gastro-oesophageal junction (GOJ) cancer that fail to respond to chemoradiotherapy have a poor clinical prognosis. Recent clinical trials have investigated the use of immune checkpoint inhibitors in these patients. The use of programmed cell death protein 1 (PD-1) inhibitors have emerged as exciting therapeutic options in other solid tumors, such as non-small cell lung cancer, renal cell carcinoma and melanoma. We assessed the efficacy and safety of PD-1 inhibitors in oesophageal and GOJ cancers.

Methods

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive electronic literature search from the EMBASE, Pubmed, Scopus, MEDLINE and Google Scholar databases was conducted up to April 1st 2021.

Results

This review identified nine eligible studies reporting outcomes of 2149 patients treated with PD-1 blockade compared with 1244 patients treated with either a placebo or the standard regimen of chemotherapy for oesophageal and GOJ cancer. Clinically significant improvements in median overall survival have been demonstrated in advanced and metastatic oesophageal and GOJ cancer while maintaining acceptable safety profiles. Promising survival data has also recently emerged from PD-1 blockade in the adjuvant setting.

Conclusions

PD-1 blockade in oesophageal and GOJ cancer has delivered impressive survival benefit whilst remaining well tolerated. Its use in the adjuvant setting may further advance our treatment options for this difficult-to-treat tumour, and more advancements in the immunotherapy landscape are highly anticipated. However, further characterization of the PD-1/PD-L1 pathway is required to optimise patient selection.
O-P06 Early postoperative differentiation between biochemical leak and clinically-relevant pancreatic fistula after pancreaticoduodenectomy: development of a predictive risk score
Authors: Raza Syed Soulat , Nutu Anisa , Powell-Brett Sarah , Boteon Amanda Carvalheiro , Hodson James , Chatzizacharias Nikolaos , Dasari Bobby , Isaac John , Abradelo Mauel , Marudanayagam Ravi , Mirza Darius , Roberts Keith , Sutcliffe Robert
Published: December 2021

Background

Several risk scores are available which predict pancreatic fistula after pancreaticoduodenectomy (PD), but do not differentiate between biochemical leak (BL) and clinically relevant pancreatic fistula (CR-POPF). The aim of this study was to identify factors that differentiate between BL and CR-POPF in the early postoperative period.

Methods

Consecutive patients diagnosed with BL and CR-POPF after PD were identified from a prospectively maintained database (2009-2019). Data were collected for demographics, intraoperative and laboratory parameters on the first five postoperative days (PODs), including drain fluid amylase (DFA), C-reactive protein (CRP) and albumin. Independent predictors of CR-POPF were identified using a multivariable binary logistic regression model, which was subsequently converted to a risk score

Results

187 patients consisted of 99 BL and 88 CR-POPF. In those with CR-POPF, the leak became clinically relevant a median of 9 days after surgery; these patients had a significantly higher length of hospital stay than those with BL (median: 24 vs. 10 days, p < 0.001). On multivariable analysis, male gender (p = 0.002), higher DFA (p < 0.001) or CRP (p < 0.001) on POD3, lower albumin (p = 0.028) on POD3 were all found to be independent predictors of CR-POPF. A risk score based on these factors returned an area under the ROC curve of 0.78.

Conclusions

In patients with a confirmed pancreatic fistula it may be possible to differentiate between BL and CR-POPF using early postoperative variables, particularly DFA, serum albumin and CRP. Early identification of CR-POPF may allow earlier intervention to improve clinical outcomes.
P-BN10 Seasonal Variation of Presentation of Perforated Peptic Ulcer Disease: An Overview of Patient Demographics, Management and Outcomes in Northern Ireland
Authors: Yawar Bakhat , Marzouk Ahmed , Ali Heba , Diab Alsarah , Abdulrahman Hassan , Asim Asim , McCann Laura , Fleville Samara , Asim Ayeisha , Bahli Zahid , Abousamra Mohammad , Ghorab Tamer
Published: December 2021

Background

Perforated peptic ulcer disease is one of the most common causes of acute peritonitis. It carries significant mortality and morbidity. Several previous studies have reported a seasonal variation in presentation of patients with perforated ulcers. Here we present this study from a Northern Irish perspective on perforated peptic ulcers.

Methods

A retrospective cohort study was conducted on perforated peptic ulcer patients who presented to Altnagelvin Area Hospital emergency department between 2015 to 2020. Data on patient demographics, clinical presentation, investigations, management and outcomes were collected. Primary outcome was to investigate if seasonality was associated with incidence of perforated peptic ulcers. Follow-up data was also collected. Seasons were defined as per UK Met Office.

Results

Results:  A total of 50 patients presented with perforated PUD. Male:female ratio was approximately 3:2. Peaks were noted in spring and winter. April was the most common month for presentation followed by December. Smoking was the most common risk factor followed by alcohol abuse. 14 patients (28%) were either very frail or had contained perforations and were conservatively managed. 3 deaths were noted (6%). 13 patients (26%) required ICU admission at some stage in their management.

Conclusions

Slight seasonal variation was noted in presentation of perforated peptic ulcers in our study with more common incidence in winter and spring months. The month of April was noted to have the peak incidence of the disease in our study.
P-BN12 Impact of covid-19 on ugi (upper gastrointestinal) tract stenting and dilatation services- prioritise, keep scoping and training
Authors: Yau Chia Chuin , Esmaily Shiran , Dwarakanath Deepak , Hancock John , Mitra Vikramjit
Published: December 2021

Background

The COVID-19 pandemic profoundly affected endoscopy services including therapeutic gastroscopy across the UK. The BSG (British Society of Gastroenterology) issued guidance for managing endoscopy services safely throughout this period. At the beginning of the pandemic in March 2020, a symptom-based questionnaire was used to screen patients for COVID-19 prior to their endoscopic procedures in our hospital (COVID-19 swabs were only carried out if patients presented with COVID-19 symptoms). From 18 May 2020 onwards, in addition to the above approach, all patients attending endoscopic procedures underwent a SARS-CoV-2 nasopharyngeal swab 1-3 days prior to the procedure. We describe our experience of UGI stenting and dilatation during the initial wave of COVID-19 pandemic in the UK. 

Aims

To assess the impact of COVID-19 pandemic on technical and clinical success of luminal dilatation and stenting in the UGI tract and ascertain the risk of procedure related complications.

Methods

A retrospective audit of a prospectively maintained endoscopy database was carried out between 18th March and 31st July. All patients were followed for 30 days. Full PPE were used.

Results

42 procedures [31 were oesophageal dilatation (21 peptic stricture, 9 radiotherapy stricture, 1 achalasia), 8 oesophageal stent insertion (6 for primary oesophageal cancer, 1 metastatic cancer and 1 secondary to external compression from lung cancer) and 3 pyloric dilatation all benign] were carried out-mean age 65 years, 64.3% males, 81% of procedures were carried out as outpatients. All procedures were performed under fluoroscopy. 41/42(97.6%) patients had a confirmed histology prior to their procedure – one patient who underwent oesophageal dilatation had a peptic stricture on endoscopy (no biopsy or imaging). 39/42(92.9%) patients had undergone CT scan and/or barium swallow prior to their first procedure. All procedures were technically and clinically successful (100%).There were no procedure related complications or mortality. There were no COVID positive swabs in the 30-day post procedure period during the entire study period. Trainees were present in 21/42 (50%) of the procedures. None of the endoscopists who were involved with these procedures were diagnosed with COVID-19 during this period. One of the nursing staff, who regularly assisted in the fluoroscopy room, was involved in a non-fluoroscopic endoscopic procedure in a COVID-19 patient (not known at the time of the procedure) and subsequently tested positive. 

Conclusions

Our study confirms that a high quality stenting and dilatation service of the upper gastrointestinal tract together with specialist registrar training can be delivered safely and effectively during the COVID-19 pandemic in appropriately prioritised symptomatic patients.
P-BN16 Gallbladder agenesis in a gentleman presenting with biliary sepsis: a case report and review of literature
Authors: Hammond Rory , Tharmaraja Thahesh , Bell Daniel , Kalidindi Venugopala
Published: December 2021

Background

Gallbladder agenesis (GBA) is a well-recognised, yet rare embryological malformation, that is thought to stem from a failure of the gallbladder and cystic duct to bud from the common bile duct in the 5th week of gestation. The anomaly has an estimated incidence of 10-65 per 100 000 and is often an incidental finding. A quarter of those affected are symptomatic, often presenting in a similar manner to cholecystitis or choledocholithiasis. There is a lack of awareness and guidance on its investigation and management, making GBA a diagnostic challenge, which often leads to unnecessary high-risk surgical exploration.

Methods

A 64-year-old man presented with right upper quadrant abdominal pain, fevers, jaundice and persistent vomiting. On examination he was confused, visibly jaundiced and septic with deranged liver function tests. An initial ultrasound scan of the abdomen revealed dilated common bile ducts, with no evidence of choledocholithiasis, however, a gallbladder could not be identified. Magnetic resonance cholangiopancreatography confirmed a ‘post-cholecystectomy’ picture, despite no history of abdominal surgery. This led us to the diagnosis of gallbladder agenesis.

Results

There are no dedicated guidelines regarding the investigation and management of GBA. Efforts have been made to stratify the diagnostic imaging of GBA. Malde et al suggest that if the gallbladder is not visualised on USS, the next most appropriate investigations in order of accuracy are MRCP, CT and ERCP, respectively. Interestingly, they further suggest that if results of imaging remain inconclusive, they should be repeated again once the acute phase of the illness or symptoms have resolved. Inadvertently, this suggestion was applied in our case, as the patient underwent a repeat MRCP following the resolution of his acute symptoms.

In our case, MRCP allowed an effective final diagnosis, avoiding unnecessary investigations and exploratory surgery. It also provided a detailed anatomical picture, excluding the possibility of an ectopic gallbladder. 

Conclusions

The present case accentuates the importance of non-invasive imaging such as MRCP in appropriately diagnosing this phenomenon and avoiding unnecessary operative exploration.
P-BN29 Laparoscopic cholecystectomy during the era of a Covid-19 pandemic; a cohort study
Authors: Davies Sian , Ghassemi Nadar , Lo Ning Yi , Rathod Sneha , Carney Alex , Ralph Alyssa , Kulendrarajah Bravean , Athwal Tejinderjit , Cheruvu Chandra
Published: December 2021

Background

The Covid-19 era has created a lot of uncertainty for management of common emergency and elective surgical conditions such as acute cholecystitis and other gallstone disease related emergency admissions. At our centre we continued to provide early operative intervention for patients presenting with biliary disease and acute cholecystitis throughout the Covid-19 era during both the 1st and the 2nd waves, despite a significant local surge in Covid-19 hospital admissions impacting on the available resources. Here we present the outcomes of our experience of managing such patients during the Covid-19 pandemic of 2020 of both 1st and 2nd waves.

Methods

A retrospective observational study was performed on all patients presenting with acute cholecystitis and biliary disease who underwent elective and emergency surgical intervention at UHNM (University Hospital of North Midlands) during the second wave of the Covid pandemic (2nd CW) between 14/10/2020 and 14/01/2021). These were then compared with patients who presented in the first Covid wave (1st CW) of 1/03/020 – 30/06/2020,) and a control group pre-covid (CG) 1/03/2019 – 30/06/2019, Patients were identified using ICD-10 codes K80 (Cholelithiasis) and K81 (Cholecystitis) and OPCS codes.J18.1 – J18.5. Primary endpoints were length of stay, 30 day readmission rates, mortality and morbidity.

Results

A total of 146 patients were identified who underwent laparoscopic cholecystectomy during the study time period (2ndCW). In comparison to 104 patients during the first covid wave cohort (1st CW) and the control group (CG) of 217 patients in the preceding non covid year. Length of stay (LOS) was significantly lower in the 2ndCW cohort in comparison to both the previous 1st CW cohort and the CG cohort (p < 0.0001), with readmissions also being statistically lower (5% vs 15% and 12% respectively p = 0.027). There was no statistical difference in outcomes for post-operative complications as per Clavien-Dindo classification.

Conclusions

Overall our study demonstrates that the recommended good practice of early surgical intervention in both emergency and elective gallstone disease can continue during the pandemic periods without any significant impact on patient care & outcomes. Also during this period length of stay was significantly shorted and lower 30 day readmission rates which are likely to be multifactorial but where lessons could be potentially learnt.
P-BN63 Requirement of preoperative group and save testing prior to cholecystectomy: A systematic review
Authors: Fadel Michael , Patel Ishaan , O'Leary Lawrence , Behar Nebil , Brewer James
Published: December 2021

Background

Group and save (G&S) testing is usually performed prior to cholecystectomy. However, there are no standard national or international guidelines regarding the routine use of preoperative G&S testing for patients undergoing emergency laparoscopy.

Methods

We evaluated the available literature on the necessity of G&S prior to cholecystectomy to determine whether this was required preoperatively. Studies from January 1980 to May 2021 assessing the requirement of G&S were retrieved from MEDLINE and EMBASE databases. Number of patients, co-morbidities, operation performed, number of patients that underwent preoperative G&S testing, perioperative transfusion rates and financial costs were extracted.

Results

We initially screened 194 studies of which 11 retrospective studies reported on cholecystectomy. A total of 177,692/474,485 (37.4%) patients underwent preoperative G&S testing with a perioperative transfusion rate of 2.07% (9803/474,485 patients, range 0.0% to 1.6%). The main preoperative risk factors, where recorded, associated with perioperative blood transfusion identified include cardiovascular co-morbidity (16/45, 35%), coagulopathy (13/45 patients, 28%), anaemia (9/45 patients, 20%) and haematological malignancy (6/45, 13%). All 11 studies concluded that routine G&S is not warranted.

Conclusions

The current evidence, though limited, suggests that G&S is not necessarily required for all patients undergoing cholecystectomy. Preoperative testing should be performed in selected cases, for example in septic coagulopathy, anaemia and haematological malignancy. There is no evidence to suggest that routine G&S screening benefits patient outcomes. Having a targeted G&S approach would reduce delays in elective and emergency lists, reduce the burden on the blood transfusion service and have financial implications.
P-EGS20 Safe emergency laparoscopic cholecystectomy in the first 12 months of the Covid-19 pandemic
Authors: Michel Martin , Fifer Helen , Moran Emily , Hammett Felix , Kronberga Madara , Khawgali Mohamed , Bonner Clare , Saab Ala , Balbola Mohamed , Saha Arin
Published: December 2021

Background

The World Health Organisation declared a global pandemic on the 11th March 2020 regarding the COVID-19 infection. This has had a dramatic impact on both acute and elective hospital services that will take a considerable time to recover from. Initial emergency intercollegiate surgical guidance released in March 2020 raised concern regarding laparoscopic surgery and advised to pursue alternative non-surgical or radiological treatment options for the safety of patients and theatre teams. The aim of this study was to assess the safety of emergency laparoscopic cholecystectomy (ELC) for patients presenting to our centre with acute gallstone pathology during the pandemic.

Methods

Retrospective analysis of all cholecystectomies undertaken in the department during the first year of the pandemic from 11th March 2020 to 11th March 2021. This period encapsulated two recognised peaks of the pandemic in the United Kingdom. Demographic data, elective/emergency, operative time, postop ITU admissions due to COVID and COVID related mortality was collected. Operative numbers and times were compared with historical data (HD) from the previous five years over the same time frame.

Results

399 laparoscopic cholecystectomies were performed during the first year of the pandemic which was less than the previous five-year average of 570 cholecystectomies per annum (30% reduction). 247 (61.9%) were performed as an emergency on patients presenting with acute gallstone pathology compared to 35% (HD) performed acutely on average historically. Average age was 56 yrs (16-88 range). Average operative time for ELC during the pandemic was 69 minutes compared to 78 minutes HD (NS). No patients were admitted to ITU with post-operative Covid infections and there were no 30 day post-operative deaths.      

Conclusions

We performed more ELC’s in the first year of the pandemic compared to the previous five-year average as we were conscious of the inevitable long waiting lists, we would certainly be faced with in the coming months. The Covid-19 pandemic was a global healthcare crisis and one the NHS had never encountered before. At the time there was no high-quality evidence on the safety of laparoscopy on patients presenting acutely. This study adds to the growing body of evidence that with consistent preoperative testing, PPE and appropriate patient flow pathways that emergency laparoscopic cholecystectomies are safe to perform in the current climate.
P-EGS21 The impact of COVID-19 on operative difficulty and outcomes of laparoscopic cholecystectomy
Authors: Pati-Alam Alisha , Vulliamy Paul , Mukherjee Dipanker , Mukherjee Samrat
Published: December 2021

Background

The COVID-19 pandemic resulted in substantial delays to surgery among patients with symptomatic gallstones due to cessation of elective surgical procedures. As this exposed patients to a longer period of time during which complications from gallstones could develop, we hypothesised that the operative difficulty and complication rate of laparoscopic cholecystectomy (LC) increased following the first wave of the pandemic.

Methods

This was a retrospective cohort study of patients receiving emergency or elective LC at a single NHS trust comprising three sites. We included patients undergoing surgery in the pre-pandemic period (July-September 2019) and after resumption of elective surgical services following the first wave of the pandemic (July-September 2020). We compared data on operative duration, length of hospital stay, complications (bile leak, bile duct injury and mortality) and need for subtotal cholecystectomy. Categorical data are reported as n(%) and were compared with Fisher’s exact test. Continuous data are reported as median with interquartile range and compared with Mann-Whitney U Test.

Results

220 patients were included; 106 in the pre-pandemic group and 114 in the pandemic group. There were no significant differences in median operative times between the pre-pandemic (91 (71-121 minutes) and post-first wave (86 (69-114) minutes) groups (p = 0.48).  The proportion of prolonged operations (over two hours) was similar in the pre-pandemic and pandemic groups (50% versus 46%, respectively, p = 0.59). Median length of hospital stay was 0 days for both groups (pre-pandemic 0 (0-1) days; pandemic 0 (0-1) days, p = 0.42)). There were no significant differences in the rates of bile leak, bile duct injury, mortality, or the conversion to subtotal cholecystectomy.

Conclusions

Interruption of elective surgery following the first wave of the COVID-19 pandemic did not result in a discernible change in the technical difficulty or complication rate of LC at our centre. Longer term studies are required to assess the effect of prolonged delays to surgery and the impact of subsequent waves of the pandemic.
P-EGS23 Efficacy of Percutaneous Cholecystostomy and Timing of Tube Removal: An Observational Study from a busy District General Hospital
Authors: Choh Clarisa TP , Majkowska Agata , Heugh Claire , Cowie Andrew S , Byrom Richard , Bennett David H , Davies Nick A
Published: December 2021

Background

Percutaneous cholecystostomy (PC) has traditionally been reserved for high-risk patients with cholecystitis who are unfit for surgical intervention, or as a temporizing measure for septic biliary patients to relieve sepsis and symptoms. However, there are currently no guidelines regarding the timing of tube removal following PC. The aim of this study is to evaluate the timing of tube removal following resolving inflammation and patency of biliary ducts, and its associated risks.

Methods

Patient notes and imaging reports were retrospectively reviewed from those who underwent percutaneous cholecystostomy from January 2015-Dec 2020. Data collected included demographic details, symptom presentation, requirement of ITU admissions, details of cholecystostomy, post-operative complications from the tube, outcomes following PC, and mortality rates within 30 days of the procedure. Patients were graded by their severity of their cholecystitis according to the 2018 Tokyo Guidelines, and these were correlated with morbidity and mortality outcomes within 1 year of the procedure.

Results

There were 55 females and 65 males, with a mean age of 75.2 years (range 45-96 years). Approximately 45% of patients were diabetic and had comorbidities. On presentation, 54% (65/120) patients had elevated inflammatory markers (WCC/CRP), and 20% of patients had associated deranged liver function tests. Majority of patients had moderate or severe acute cholecystitis, with over 25% (31/120) of patients presenting with sepsis, and 6 required admission to intensive care. The median time from diagnosis of acute cholecystitis to percutaneous cholecystostomy was 8.5 days (range 1-64 days). Tube removal was performed after a median time of 31 days (range 1-142 days). Morbidity rate was observed to be 8-10%, comprising of complications such as tube displacement, leakage around the drain, bleeding and liver abscesses. Only 18.3% (22/120) of patients were deemed to be fit for further surgical intervention, of which 13 of those underwent a cholecystectomy thereafter. Unsurprisingly, 38% of these patients had recurrent biliary symptoms, and a 30% mortality rate.  

Conclusions

Percutaneous cholecystostomy is a safe option in high-risk surgical patients for symptom relief, and is a crucial step in temporizing and de-escalating sepsis. However, this study suggests that timing of cholecystostomy removal is variable, and is associated with high morbidity. Consideration needs to be given to shorten the time to tube removal, to minimise risks, if certain criteria are met to ensure safety and efficacy.
P-EGS27 Outcomes of disorders of the gallbladder, biliary tract, and pancreas during COVID pandemic
Authors: Thomas Christophe , Dowker Freddie , O'Connor Hettie , Horgan Liam
Published: December 2021

Background

Biliary disorders make up a significant proportion of the acute general surgical workload. Effective management allows definitive treatment with relief of symptoms and reduced impact to patients due to recurrent admissions and complications. During the first COVID-19 wave and lockdown there were reduced surgical presentations to hospital and patients presented later. Surgical services were forced to implement different practices including more conservative/non operative management potentially increasing the possibility of recurrent presentations and greater complications in biliary-pancreatic presentations.

Methods

We performed a retrospective audit of patients presenting to our unit with ICD 10 codes: K80;Cholelithiasis, K81;Cholecystitis and K85;Acute pancreatitis. We used the period of the first wave of the COVID pandemic March – August 2020(COVID) and compared this to the same period in 2019(pre-COVID). On note review those with inaccurate coding were excluded. Patient demographics, admission details, investigations, surgical management, operative details, and post-operative complications were recorded. The primary outcomes were change in operative management, representation, and post-operative complications. χ2 test was used to test for significance of categorical variables.

Results

Conclusions

The two groups were demographically similar with equal spread of primary diagnoses however there were significant differences in outcomes. Patients presenting with cholecystitis and gallstone pancreatitis had significantly reduced rates of definitive management. The increase in adverse operative findings is likely secondary to patients presenting later and initial conservative management. The increase in complications for the COVID cohort correlates with the increase in adverse findings/operative complexity. Conservative management with the aim of reducing COVID exposure inadvertently resulted in increased risk to patients with increased presentations/admissions. Despite this risk there were no COVID cases in our cohort.
P-EUS03 Risk prediction in patients undergoing Endoscopic Necrosectomy for infected pancreatic necrosis
Authors: Britton Emily , Smith Eleanor , Hollyman Marianne , Strickland Andrew
Published: December 2021

Background

Laparotomy for the treatment of patients with infected pancreatic necrosis is associated with high rates of morbidity (∼95%) and mortality (∼50%); this has driven the development of minimally invasive alternatives for the treatment of such cases. Endoscopic Transgastric Necrosectomy (ETN) is an accepted method for debriding infected necrosis in these challenging cases. The National Emergency Laparotomy Audit (NELA) and P-POSSUM scoring systems are well-validated risk stratification tools used nationally for patients undergoing emergency laparotomy. This work aims to determine whether patients undergoing ETN for infected pancreatic necrosis can be risk stratified accurately using both the NELA and P-POSSUM scoring systems.

Methods

A prospective database of all patients in a single UK centre undergoing ETN from 2011 to 2021 for infected pancreatic necrosis has been maintained.  All patients initially underwent an EUS guided stent placement to create a cystgastrostomy before subsequent transgastric necrosectomy.   

Patient demographics, timing of procedures and short-term post procedural outcomes were recorded. The NELA and P-POSSUM score was calculated at the time of the endoscopic cystgastrostomy. 

Demographic data were descriptively summarized and ROC analysis was performed to assess the diagnostic accuracy of both the P-POSSUM and NELA score. Data are presented as median (range)

Results

Sixty-nine patients underwent ETN between 2011 and 2021 with a median age of 54 years-(15-86). Twenty-nine patients-(42%) required ITU admission during their admission.

The actual mortality was 10.1%-(7), which was slightly higher than the median of the NELA predicted mortality-(6.7%) but half the median of the P-POSSUM predicted mortality-(21.1%).

Median overall predicted mortality for ETN using P-POSSUM was 21.1%-(2.6-85.7%) and with NELA was 6.7%-(0.4-34.3%). The median P-POSSUM score of the patients who died was 33.2%-(6.9-52.4%) compared to the median NELA score which was 17.2%-(0.8-34.3%). The area under the receiver operating characteristics curve-(AUROC) was similar for both the NELA-(0.82, SE = 0.13) and P-POSSUM-(0.75,-SE=0.1).

Conclusions

Endoscopic Transgastric Necrosectomy is a safe alternative to emergency laparotomy for the debridement of infected pancreatic necrosis.  Both the NELA and P-POSSUM scoring systems can effectively stratify those patients at highest risk, however where P-POSSUM scoring may overestimate mortality NELA scoring may underestimate the severity of illness and mortality associated with the disease.
P-L15 Fluorescence guided laparoscopic resection of Colorectal Liver Metastases: Same day administration of indocyanine green with use of SPY- Colour Segmented Fluorescence imaging to identify tumours intra-operatively
Authors: Benjafield Anastasia , Tanase Andrei , Aroori Somaiah
Published: December 2021

Background

Near-infrared fluorescent (NIRF) imaging using indocyanine green (ICG) has various applications in minimally invasive surgery. There are a number of techniques in timing and dose administration. Visually different fluorescent enhancement patterns correlate with different pathologies to aid identification of lesions intra-operatively. The aim of this study is to present our experience with utilisation of Colour Segmented Fluorescence ICG mode in laparoscopic liver surgery for colorectal liver metastases. 

Methods

We present a single surgeon (SA) experience with the use of laparoscopic fluorescence guided imaging surgery (L-FGIS). Between November 2020 and July 20201, L-FGIS was used in seven patients with suspected CRLM. ICG was administered intravenously at a dose of 0.2 to 0.3 mg/kg IV 2-3 hours prior to liver surgery. Through use of the SPY Colour Segmented Fluorescence (CSF) imaging mode, the image is scaled as to NIRF fluorescence intensity to allow for the clear identification of the CRLM intra-operatively. 

Results

A total of seven patients (Four males) with median age of 74.3 years (range: 30.5 -86) underwent L-FGIS during the study period. Two out of seven patients underwent re-do liver surgery. The median size of the tumour was 27mm (range: 10-65mm) and median number of tumours were one (range: 1-2). To visualise the tumour and to avoid interference of green background liver, ICG camera was switched to CSF mode. All lesions had signet ring appearance under CSF mode (see figure 1). Except in one patient (necrotic lesion), the histology of resected specimen contained a well to moderately differentiated colorectal adenocarcinoma metastasis. R0 resection was achieved in all patients and median clearance of the tumour was 3mm (range 0.4-10mm).  

Conclusions

In our limited experience ICG administered at least 2-3 hours prior to surgery can identify superficially located colorectal metastases, provided ICG camera is switched to CSF mode. Superficially located lesions are easily identifiable under CSF mode. CSF mode helped us to identify the lesions and to mark the resection margin. The use of ICG is an important advancement in CRLM surgery and further research is needed to optimise image interpretation and correlate with clinical resection outcomes.
P-O03 The Management of Gallbladder Polyps at a Single Trust: Are we compliant with European Guidelines?
Authors: Jamieson Elias , Short Chloe , Clifford Rachael , Rajput Kunal
Published: December 2021

Background

Gallbladder polyps affect approximately 5% of the global population, with rates highest in those of Indian descent. 10% of polyps will have malignant potential based on their size or rapid growth rate, which are associated with a poor 5-year survival once advanced of less than 25%. As gallbladder polyps are common but gallbladder cancer is rare, it is a diagnostic challenge to determine which polyps are likely to be malignant. Adherence to guidelines regarding radiological follow up and definitive treatment, in the form of a cholecystectomy, is therefore vital.

Methods

Retrospective data collection and analysis was completed for all patients who had a biliary ultrasound between December 2013 and December 2016 to enable 5-year follow up, and a snapshot of 47 patients selected at random. Patients having a gallbladder “polyp” documented on their scan report were eligible for inclusion and adherence to European Society of Gastrointestinal and Abdominal Radiology (ESGAR) guidelines was assessed.

Results

Within the cohort there was a mean age of 56 years, with a male:female ratio of 17:30. All patients included were Caucasian, with 41 reporting “biliary symptoms” as the indication for the primary ultrasound. 26 patients were not followed up in adherence to guidelines, with 50% due to the sonographer reporting follow-up was not indicated on initial scan, 5 having unchanged polyp size and 2 discharged by the responsible consultant. Of the 21 who were followed up according to guidelines, 20 had a cholecystectomy within 5years, with none of these patients having cancer detected on histology.

Conclusions

Over 50% of patients within our cohort were not followed up according to the ESGAR guidelines. Although no patients in the study were found to have malignant polyps, the sample size is relatively small and limited to low-risk groups. We aim to expand this audit both locally and regionally, raise awareness of the importance of surveillance across the multi-disciplinary team, and produce local guidance for the outpatient setting.
P-O05 Deconstructing Operations to Improve Recording of Surgical Training Experience
Authors: Dewi Ffion , Scroggie Darren , Pathak Samir , Blencowe Natalie , Hollowood Andrew , Strong Sean , Jah Asif , Smith Andrew , Van Laarhoven Stijn
Published: December 2021

Background

A new outcomes-based curriculum is soon to be implemented for UK surgical trainees. Performance will be evaluated against the standard expected of a new consultant. Accurate recording of operative experience and performance will therefore be crucial to demonstrate achievement of this standard. The current eLogbook system for recording surgical experience has many benefits including simplicity and accessibility, but may misrepresent actual experience because most operations are considered as a whole; unlike some colorectal operations, involvement in steps within many upper gastrointestinal (UGI) operations cannot be recorded.

Methods

Impact on training by the COVID-19 pandemic led to discussion and identification of cultural and logistical barriers to accurate recording of experience. To address these, a modification to enhance the current eLogbook system was developed by trainees and trainers at a university teaching hospital. An existing typology was used to deconstruct common UGI operations into their component steps, which can be recorded at this more detailed level. 

Results

The modified deconstructed logbook concept is described using a worked example, which can be applied to any operation. We also describe the integration of a component-based training discussion into the surgical team brief and debrief; this complements the deconstructed logbook by promoting a training culture.

Conclusions

Using the described techniques, trainees of all levels can comprehensively and accurately describe their surgical experience. Senior trainees will benefit from recording complex operations which they are not expected to complete in their entirety, whilst less experienced trainees will benefit from the ability to record their involvement in more basic parts of operations. The suggested approach will reduce misrepresentation of experience, encourage proactive planning of training opportunities, and reduce the impact of crises such as pandemics on surgical training.
P-O10 Mortality and Morbidity Reporting Quality
Authors: Abbas Kazim , Kausar Ambareen , Chang David
Published: December 2021

Background

Mortality and morbidity (M&M) meetings in surgery are an important quality assurance process. These meetings contribute to learning, education and improvements in patient care. In order to achieve these outcomes effectively, M&M meeting require robust structure and process including accurate documentation of complications. Our hepato-pancreatico-biliary (HPB) unit conducts and records weekly M&M meetings based on consultant reported complications. However as there was no standardized documentation method of complications there was possible under-reporting. This realisation acted as a basis to investigate the robustness of our current reporting methodology of surgical complications and recommend changes in practice to achieve quality improvement.

Methods

Patients were selected retrospectively (May 20 - Sep 20) from M&M recording excel sheet which is maintained through our weekly meetings. Patient undergoing major HPB cancer resections were included. Day case procedures were excluded. 

Complications reported on excel sheet were compared against any additional mis-reported complications through review of online discharge letters, discharge summaries & investigations.

The primary aim of this quality improvement project was to identify mis-reported complications. The secondary aims were to compare any change in Comprehensive complication Index (CCI) following addition of mis-reported complications.

Results

Total number of patients included in the study were n = 46. Postoperative surgical complications were recorded for n = 27 patients. 19 patients were identified to have unreported complications. Total number of unreported complications were 34. This amounted to average unreported complication per case at 1.78. Average CCI score was 14.4 before inclusion of unreported complications. There was a significant rise in average CCI score to 35.8; an increase of 21.6 CCI score after inclusion of unreported complications.

Conclusions

Unreported complications following major HPB cancer resection impact the quality of learning and education process in M&M meetings. It is essential to make complications reporting a robust process to prevent mis-reporting. We recommended use of Clavein-Dindo complications grading form as part of surgical clerking. This would help real time recording of surgical complications during postoperative journey of patients, help capture even minor complications. It would also be recommended to get these forms countersigned by responsible consultants before discharge of patients.
P-O13 Spontaneous Splenic Rupture as first presentation of Chronic Myeloid Leukaemia
Authors: McCollum Catherine , Khan Khurram , Gall Lewis , Macdonald Andrew
Published: December 2021

Background

Although rare, spontaneous splenic rupture (SSR) is a potentially life threatening condition and most commonly associated with infection and malignancy. Haematological malignancies are an important differential diagnosis and among these chronic myeloid leukaemia (CML) has one of the highest associations with SSR.

Methods

This case report follows a previously fit and healthy thirty-three year old gentleman who presented to accident and emergency with one day history of sudden onset, severe, left upper quadrant pain. CT of the abdomen and pelvis including an arterial phase, confirmed splenic rupture with moderate volume haemo-peritoneum, but no active bleeding. White cell count (WCC) was 225.8 x10^9/l and blood film confirmed suspicion of haematological malignancy. The patient was haemodynamically stable and therefore transferred to the surgical high dependency unit for observation and conservative management. He was commenced on hydroxycarbamide on the advice of haematology.

Results

Genetic screening detected BCR-ABL1 and Philadelphia chromosome; this along with bone marrow aspirate confirmed diagnosis of CML. His WCC decreased with hydroxycarbamide therapy. He made good clinical progress and was discharged home with haematology follow up. Hydroxycarbamide has since been stopped and he has been initiated on Imatinib therapy. His WCC has returned to normal and he has remained well with no further complications.

Conclusions

SSR is an extremely rare first presentation of CML. Given its associated morbidity and mortality, it should remain an important differential diagnosis in patients presenting acutely to the General Surgeon with abdominal pain and shock, especially in those with a known underlying haematological malignancy.