bluuebunny/crossref_metadata_2025 huggingface dataset:
OGBN P13 Laparoscopic splenectomy for massive splenomegaly: Is it feasible?
Authors: Elshaer Ahmed , Kaur Mandeep
Published: November 2023

Background

Laparoscopy has high credibility in the treatment of normal sized and mildly enlarged spleens. However, there is lack of evidence for its safety for cases with massive splenomegaly. EAES defined massive splenomegaly by maximum splenic diameter exceeding 20 cm. It recommended hand assisted laparoscopic splenectomy (HALS) or open surgery as a treatment for such cases. In this video, we demonstrated the feasibility of the use of laparoscopy in cases with massive splenomegaly with favourable outcomes.

Methods

We describe a video for a 36 years old female patient who is known Kikuchi syndrome. She had massive splenomegaly which reached 25 cm in its maximum length. Patient was in right lateral position. Camera port was located left to the umbilicus, another 10 mm port at left midclavicular line and two 5 mm ports were used (one at epigastrium and assistant port at left anterior axillary line). The video demonstrates the steps of laparoscopic splenectomy with the challenges of the huge size of the spleen. Specimen was taken through patient’s old caesarean scar (Pfannenstiel incision).

Results

Patient had CT scan on day 2 for raised inflammatory markers, which showed small collection at splenic bed which was treated conservatively. Patient was discharged on day 5 postoperatively after removal of surgical drain. Clinical review after 4 weeks post discharge didn’t show any clinical concerns.

Conclusions

Using a stepwise laparoscopic approach is feasible and safe for massive splenomegaly cases. Refining the selection criteria for laparoscopic versus open or HALS splenectomy should be revised with less consideration to the size of spleen as a limiting factor.
OGBN P15 The cost-effectiveness of a novel implantable device for treating gastro-oesophageal reflux disease in the United Kingdom
Authors: Mealing Stuart , Harper Sam , Grodzicki Lukasz , Gemmill Liz , Goldsmith Paul , Ahmed Ahmed
Published: November 2023

Background

Gastro-oesophageal reflux disease (GORD) is a common gastrointestinal condition characterized by heartburn, chest pain, and regurgitation. Chronic treatment with proton pump inhibitor (PPI)-based medical management is the current standard of care, with antireflux surgery considered in selected patients. RefluxStop is a novel implantable device indicated for patients eligible for laparoscopic anti-reflux surgery. The purpose of this analysis was to assess the cost-effectiveness of RefluxStop against other GORD treatment options in the UK.

Methods

A Markov model was developed to assess the cost-effectiveness of RefluxStop compared with PPI-based medical management, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation (MSA) for management of GORD. The UK National Health Service perspective was adopted, with clinical outcomes and costs estimated over a lifetime horizon and an annual discount rate of 3.5% applied. Clinical efficacy data for RefluxStop was obtained from its CE mark study, and comparator treatments were based on published literature.

Results

RefluxStop demonstrated favorable surgical outcomes compared to both laparoscopic Nissen fundoplication and MSA. The base case incremental cost-effectiveness ratios (ICERs) compared with PPIs, laparoscopic Nissen fundoplication, and MSA were £4,156, £6,517, and £249 per quality-adjusted life-year (QALY) gained, respectively. With a UK cost-effectiveness threshold of £20,000 per QALY gained, the probabilities that RefluxStop was cost-effective compared with PPIs, laparoscopic Nissen fundoplication, and MSA were 100%, 93%, and 100%, respectively.

Conclusions

Based on this analysis, RefluxStop was estimated to improve quality of life and extend life expectancy in GORD patients when compared to PPIs, laparoscopic Nissen fundoplication, and MSA. Furthermore, this analysis demonstrated that RefluxStop is highly likely to be a cost-effective option for treating GORD in the UK.
OGBN P16 Endoscopic surveillance allows prediction of burden of early signet ring cell carcinoma in Hereditary Diffuse Gastric Cancer syndrome
Authors: Jun Lim Hui , YC Lee Colin , Karthik Nandini , O’Donovan Maria , Fitzgerald Rebecca C , O’Neill J Robert , di Pietro Massimiliano
Published: November 2023

Background

Hereditary diffuse gastric cancer (HDGC) syndrome is commonly linked to CDH1 germline pathogenic variants (PV) and carries a high lifetime risk of diffuse gastric cancer (DGC). Definitive treatment remains prophylactic total gastrectomy (PTG). However, endoscopic surveillance can be offered to inform decision-making around surgery, although the optimal time for treatment escalation remains unclear. This study aims to establish whether histopathological assessment of endoscopic biopsies can predict burden of early signet ring cell (SRC) carcinoma on PTG specimens.

Methods

We performed a retrospective review of prospectively collected data on endoscopic and surgical histopathologic results from CDH1 PV carriers who underwent PTG at Addenbrooke’s Hospital between January 2006 and May 2023. Targeted and systematic Cambridge protocol biopsies were performed. Patients with confirmed DGC (stage 2 or higher) at baseline endoscopy were excluded. Pearson correlation was performed to assess the relationship between number of SRC foci on endoscopy and surgical specimens.

Results

46 patients underwent PTG with median of 3 pre-operative surveillance endoscopies over 22 months. Final stage was pT1aN0M0 in 41 patients and pT0N0M0 in 5 patients. The number of SRC foci on PTG specimens ranged from 0 to 273. There was a strong correlation between number of SRC foci on gastrectomy specimens and from targeted and random biopsies when evaluated separately and together for last 2 and all endoscopies. The strongest correlation was seen with total number of SRC foci on random biopsies for last 2 endoscopies (r=0.738, p-value<0.001). Random biopsies outperformed targeted biopsies in prediction of early SRC burden.

Conclusions

Endoscopic surveillance with systematic targeted and random biopsies by expert endoscopists within a dedicated specialist service provides useful information to estimate the burden of early SRCC. Low number of SRC foci at last two endoscopies indicate scarce gastric neoplastic involvement.
OGBN P21 Improving patient satisfaction with discharge information after laparoscopic cholecystectomy: a quality improvement project
Authors: Fardanesh Armin , Refaat Daniel , Stavropoulou-Tatla Stavroula , Atiyah Ayah , Cullinan Bridget , Jones Liam , Rohatgi Ashish
Published: November 2023

Background

With the rise in day case surgery, there has been an increase in both nurse-led discharge and patient turnover. Patients recovering from anaesthesia frequently retain less, therefore information delivered to patients regarding post-operative recovery is sometimes lost or forgotten.

The aim of this quality improvement project was to improve both the quality of information and the patient satisfaction with the information provided to them upon discharge following laparoscopic cholecystectomy.

Methods

Patient satisfaction was assessed using questionnaires at baseline and following each Plan- Do-Study-Act (PDSA) cycle. In PDSA 1, a generic discharge summary delivering standard post-operative instructions, was distributed to patients on discharge. For PDSA 2, a detailed leaflet, encompassing information requested by previously surveyed patients, entitled “going home after your gall-bladder surgery” was provided in addition to the discharge summaries.

Results

At baseline we found all patients were receiving some sort of discharge information after laparoscopic cholecystectomy. Key information such as wound care, dietary advice and expected pain, was frequently missed. We found that patients were not satisfied, with an average reported satisfaction of 55%. After PDSA 1 patient satisfaction rose to 66%. However,the generic discharge summary missed advice for patients going home with drains and driving advice. With introduction of the detailed leaflet, patient reported satisfaction reached 100%.

Conclusions

Introducing detailed discharge leaflets improved the patient satisfaction with the information they received on discharge. We anticipate this will in turn reduce patient concerns and need to seek further medical attention. Similar leaflets can be distributed for day case operations such as hernias. This serves as a useful measure to aid patient recovery at home and supports a high turnover day case surgery list.
OGBN P22 The safety and efficacy of the Gastric Electrical Stimulator (GES) for gastroparesis in pregnancy
Authors: Archer Matthew , Askari Alan , Kadirkamanathan Sritharan
Published: November 2023

Background

Gastroparesis, a severe illness, can considerably complicate pregnancies. A large proportion of patients suffering from gastroparesis are female and often of child bearing age. This study explored the Gastric Electrical Stimulator's (GES) safety during pregnancy and evaluated outcomes such as symptom control and Quality of Life (QoL).

Methods

We examined our gastroparesis patient database to identify pregnant women with in-situ GES. The key outcomes included GES safety and efficacy during pregnancy. Metrics such as QoL SF36 scores, nausea, vomiting, pain, satiety, bloating, hospital stay, admissions, and feeding support were evaluated pre- and post-operatively.

Results

Twelve women with in-situ GES became pregnant. Median age at surgery was 29 years (IQR: 26-31 years), with 58% having diabetes as their gastroparesis cause. A majority (67%) underwent robotic GES insertion. Post-operative improvement was seen across several metrics, including nausea score (from 4 to 1), vomiting score (from 4 to 0), pain score (from 4 to 1), satiety score (from 4 to 0), and bloating score (from 4 to 0). SF36 scores significantly increased from a median pre-operative score of 261 (IQR: 178-65) to 1,783 (IQR: 765-3,527, p<0.001). Also, 58% transitioned from assisted feeding to no feeding support.

Conclusions

For pregnant patients, GES implantation safely improved gastroparesis symptoms, enhanced QoL as per SF36 scores, and reduced feeding support reliance. More extensive research is required to confirm these findings and understand GES's implications in pregnancy-related gastroparesis.
OGBN P29 Short term outcomes after anti-reflux surgery for Gastro-Oesophageal Reflux disease
Authors: Patel Maitreyi , Suresh Reena , Woods-orugboh James , Shetty Jeevith , Amalesh Thangadorai , Mukherjee Samrat , Mukherjee Dipankar
Published: November 2023

Background

Laparoscopic fundoplication is the standard surgical practice for management of Gastro-oesophageal reflux Disease (GORD). However, post operative complications and recurrence can be problematic. We conducted this study to assess short-term post operative outcomes following anti-reflux surgery (ARS) for GORD at our UGI surgery unit at a busy District General Hospital (DGH).

Methods

All patients above 18 years of age undergoing ARS between January 2016 and December 2021 were included. We excluded patients who underwent fundoplication as part of treatment of achalasia or large hiatus hernia repairs. Data was collected retrospectively from a prospectively maintained database. Pre –operative investigations and surgical procedure was recorded. Primary outcome assessed were post-operative complications recorded as per Clavien-Dindo grade and re-operation rates. Secondary outcomes assessed were symptomatic relief and proton pump inhibitor (PPI) discontinuation.

Results

86 patients were included. The median age at surgery was 52 years. 98% patients had typical symptoms of GORD at presentation. On pre-operative OGD, 29% patients had oesophagitis and 77.91% had hiatus hernia. 79 (91.86%) patients underwent pH manometry. 97.67% patients underwent Nissen fundoplication. All cases were successfully completed laparoscopically with no conversions to open. The median post-operative length of stay was 1 day. 93.02% had no post operative complications, and none had 30 day re-operation. At 1-year follow up, 97.67% patients reported improvement in symptoms and 94.19% patients were able to stop PPI use.

Conclusions

Laparoscopic fundoplication provides excellent relief of GORD symptoms with low incidence of post operative complications and re-operation rates.
OGBN P30 Post-operative and symptomatic outcomes following Laparoscopic Hellers Cardiomyotomy- single centre experience
Authors: Patel Maitreyi , Suresh Reena , Woods-orugboh James , Shetty Jeevith , Amalesh Thangadorai , Mukherjee Samrat , Mukherjee Dipankar
Published: November 2023

Background

Esophageal achalasia represents a uncommon primary oesophageal motility disorder secondary to loss of inhibitory neurons in the oesophageal myenteric plexus level. The main goal of treating oesophageal achalasia is to relieve dysphagia secondary to the functional obstruction of the distal oesophagus by the inability of the Lower Oesophageal Sphincter (LOS) to relax appropriately after deglutition. The Eckardt score (ES) was developed to objectively assess the symptom severity and continues to be widely used. Aim of this study was to assess the post-operative outcomes and symptomatic improvement using ES in consecutive patients undergoing laparoscopic Hellers cardiomyotomy for achalasia in our unit.

Methods

Data of consecutive patients who underwent LHCM between January 2016 and December 2021 was collected. Patient demographics, surgical details, perioperative course, ES, and manometric data including Integrated Relaxation Pressure (IRP), were retrieved from a prospectively maintained database. Primary outcomes assessed were peri-operative morbidity assessed using Clavien-Dindo grade. Secondary outcomes assessed were improvement in symptoms using ES (pre- and post-operative). ES of ≤3 was considered as symptomatic improvement. Data was analysed using Microsoft Excel. Comparison of pre-operative and post-operative means was performed using paired t test. Fishers exact test was used for categorical variables. A p-value <0.05 was considered statistically significant.

Results

41 patients underwent LHCM. Twenty-one were males. Median age was 56 years (20-77). 95.12% patients had dysphagia for a median duration of 24 months (2-180). Type II achalasia was most common in 87.80%. Median IRP was 22.3 mm Hg (11-78). Oesophageal dilation was performed in 2 while, 10 patients received botulin injection pre-operatively. Median hospital stay was 1 day (1-12). 92.68% had no post operative complications. None of the patients had significant complications (Clavien-Dindo >grade 2). At a median follow-up of 60 months, there was significant improvement in ES 8±1.97 to 1.82±1.16, p<0.001 and dysphagia score (p<0.001).

Conclusions

LHCM with fundoplication leads to significant symptomatic improvement with excellent short and medium term outcomes with low morbidity and complication rates. A detailed pre-operative discussion with patients is essential to provide tailored treatment as per individual patient symptoms.
OGBN P31 Laparoscopic versus open repair of giant paraoesophageal herniae: a 4-year retrospective study
Authors: Butterworth James , Dawas Khaled , Silver Amy
Published: November 2023

Background

Although laparoscopic repair of giant paraoesophageal hernia (PEH) has known advantages over open repair including a reduced post-operative length of stay (LOS) and reduced post-operative pain, there has been concern amongst surgeons regarding the recurrence rate. We sought to further analyse differences in outcomes in a retrospective series of patients with giant hiatus hernia in a single tertiary centre.

Methods

All giant PEH receiving operative repair at a tertiary referral centre (UCLH) were reviewed retrospectively over a one-year period from July 2019-July 2022. Diagnosis was made on gastroscopy and computer tomography (CT). A giant PEH was defined as one in which the hernia contained at least 50% of the stomach. If the patient was symptomatic post-operatively they were investigated for recurrence with gastroscopy and CT.

Results

The laparoscopic cohort (n=14, median age of 72 years, ASA 2) had similar demographics to those receiving open repair (n=21, median age of 68 years, ASA 2.5). Median length of stay was shorter in the laparoscopic cohort compared to the open cohort (3.5 days (1-7) versus 7 days (5-9)). The laparoscopic and open cohorts had similar rates of minor complications (42.8% (6=2, Clavien Dindo 2) versus 47.6% (n=10, Clavien Dindo 2))respectively. Recurrence of reflux or dysphagia symptoms was higher in those who had a laparoscopic repair (28.6% versus 14.3%). One radiologically confirmed recurrence occurred in the open group (4.7%).

Conclusions

Although the benefits of a faster post-operative recovery with a shorter LOS were clear in the cohort following laparoscopic repair, a higher rate of recurrence of symptoms was evident within those receiving a laparoscopic repair. Large, controlled, prospective studies with long-term follow-up are required in order to further establish differences in outcomes between laparoscopic and open repair of giant PEH.
OGBN P35 The effect of social deprivation in patient outcomes following cholecystectomy
Authors: Yee Kuan Jen , Peter Vaz Osborne , Fitzpatrick Stephanie , Khan Rehan , Rajendran Ilayaraja
Published: November 2023

Background

Socio economic status (SES) has shown to impact patient outcomes in different types of cancer. Socio economically deprived populations experience severe as well as complicated gall stone diseases more frequently in comparison with their affluent counterparts (doi: 10.1089/heq.2022.0063). However, the impact of SES on the presentation and outcomes of gallstone disease(GSD) in deprived population is not well studied. Therefore, a study was set up to assess the impact of deprivation in patients presenting with GSD.

Methods

A retrospective observational study of cholecystectomies in adults in our trust from August 2022 to December 2022 was performed. Patients were assigned into Affluent(AF) and Non-Affluent(NA) groups based on the Index of Multiple Deprivation (https://data-communities.opendata.arcgis.com/datasets/communities::indices-of-multiple-deprivation-imd-2019-1/explore). Data was collected using MS Excel and analysed using IBM SPSS statistics ver 27.

Results

100 patients were included from August to December 2022. Male female ratio was 1:3. The five most deprived deciles (NA) had 46 and the five least deprived deciles (AF) had 54 patients. Median age in years was 48 and 52.5 respectively (p = 0.10). The NA deciles had 37 patients referred via the emergency department (ED) and 9 via GP. AF deciles had 34 referrals via ED and 20 via GP (p=0.05). No statistically significant difference was observed in Charlson’s index (p=0.53), operative time (p=0.58) and length of stay (p=0.74) between the groups. There were no conversions to open.

Conclusions

A higher ratio of patients came via GP referrals in the affluent deciles whereas more patients were referred via the ED in the non affluent deciles. However, there was no statistically significant difference in time to surgery and outcomes between these two groups.
OGBN P36 Surgical Consideration in Patients with Ineffective Oesophagus: Implications for Low Risk of Dysphagia and Suitability for Antireflux Operation
Authors: Miah Ismail , Wong Terry , Gossage James , Zeki Sebastian , Jafari Jafar
Published: November 2023

Background

Ineffective oesophageal motility (IOM) is a minor motility disorder that is commonly found in patients. The IOM diagnosis is based on heterogenous combination of failed peristalsis, weak peristalsis activity and peristaltic defects that are observed during the stimulation to 5mL standard water swallows. IOM is implicated to post-surgical dysphagia and therefore influences the surgical decision making. This paper will address this topic.

Methods

A retrospective review was conducted on patients who underwent oesophageal high-resolution manometry (HRM) between March and May 2023. The diagnosis of IOM was based on the international Chicago Classification guideline (version 4.0). Patients' oesophageal motility profiles were assessed for peristaltic reservation (PR) and oesophageal contractile mean wave amplitude (MWA). PR >100% in IOM patients indicates low risk of dysphagia after laparoscopic Nissen fundoplication (LNF). Similarly, normal MWA indicate a low risk of dysphagia in considering patients for Magnetic Sphincter Augmentation (MSA).

Results

120/270 patients (44.4%) were diagnosed with IOM (female:male=86:34, median age 52 years old). Mean PR in IOM patients was 217.8% [95%CI:181.2%-254.4%] with 60.8% demonstrating PR >100%. Average MWA found in IOM patients was 40.8mmHg (95%CI:38.5mmHg-43.1mmHg) with 38.3% demonstrating normal MWA. 13.3% (16/120) of patients did not invoke peristalsis on MWS, but 6 of the 16 patients showed normal MWA. 24.2% (29/120) patients demonstrated PR >100% and normal MWA. 14.2% (17/120) of patients showed adequate PR and weak MWA and pose risk of postsurgical dysphagia. 75% (90/120) of patients with IOM were suitable for at least one antireflux operation.

Conclusions

Approximately half of the oesophageal physiology patients have IOM and three-quarters of these patients are suitable for at least one form surgical intervention with low risk postsurgical dysphagia. Only 14.2% of patients with IOM pose a risk of post-surgical dysphagia. The overall findings suggests that surgical intervention may be a viable option for patients with IOM that could potentially improve their quality of life and prevent reflux oesophagitis/pre-cancerous Barrett’s oesophagus. This study was limited by not investigating the relationship between IOM pathophysiology and the reflux oesophagitis severity grade.
OGBN P38 Adherence to AUGIS Guidelines in Index Admission Cholecystectomy: Impact on Hospital Recurrences
Authors: Alwani Omneya , Nasim Mazhar , Hassanein Mohamed , Patel Anish V , Patel Aminah , Baltatzis Minas , Alasmar Mohamed
Published: November 2023

Background

This study aims to assess adherence to AUGIS guidelines for index admission cholecystectomy and investigate the effects of non-compliance on hospital readmissions and cost implications.

Methods

A retrospective analysis was conducted on 105 patients admitted to the surgical department at Salford Royal Hospital between October 2022 and January 2023. Unfit patients and those who refused surgery were excluded, resulting in 96 eligible patients fit and approved for index admission cholecystectomy.

Results

Out of 105 patients, 96 were eligible for surgery, with 15 (15.62%) undergoing index admission laparoscopic cholecystectomy, 9 (9.37%) having laparoscopic cholecystectomy during readmissions, and 42 (43.75%) receiving elective surgeries. Thirty patients (31.25%) had no operation. The average number of hospital admissions was 1.96, and the average stay for index admission laparoscopic cholecystectomy was 7.07 days. Eligible readmissions had an estimated average stay of 11.14 days. Based on these numbers, the estimated extra days of hospital stay during the study period and up until July 1st, 2023, were 329.5 days.

Conclusions

Non-compliance with AUGIS guidelines led to hospital readmissions and prolonged stays. Conversely, adherence to the guidelines significantly reduced recurrence rates and healthcare expenses. Emphasizing a Gallbladder pathway is critical for achieving optimal surgical outcomes and cost-effective patient care.
OGBN P39 Feasibility and Safety of Laparoscopic Anti-Reflux Surgery at a District General Hospital: Matching National Standards and Improving Patient Quality of Life
Authors: Livingstone James , Nanda Akriti , DiMaggio Francesco , Thomas Rhys , Rock Caitlin , Kyrtsonis Georgios , Rothnie Alex
Published: November 2023

Background

Gastro-oesophageal Reflux Disease (GORD) affects a substantial proportion of adults in the UK, with surgery offering superior short-to-medium term benefits compared to medical management alone. However, there is significant variation in surgical practice nationwide. This study aimed to assess the feasibility and safety of laparoscopic anti-reflux surgery (LARS) at a District General Hospital (DGH) by aligning outcomes with the national standards set by AUGIS (Association of Upper Gastrointestinal Surgeons).

Methods

Prospective data from patients who underwent LARS between May 2022 and May 2023 were collected and recorded locally as well as on the National Hiatal Surgery Register (NHSR). Pre-operative symptoms and investigations, intraoperative findings, post-operative short and medium-term outcomes, and patient-reported outcome measures (PROMs) were analyzed. Quality of life (QoL) questionnaires, administered by the NHSR, were collected at 6 months to 1 year post-surgery. AUGIS standards, including a minimum of 5 procedures per year by 2 surgeons, conversion rate below 5%, 30-day return to theatre below 5%, and 30-day readmission rate below 10%, were utilized for comparison.

Results

In one year, two surgeons performed 41 LARS procedures: 31 Nissen, 4 Toupet, and 2 Dor wraps, with 2 redo surgeries. Minor complications occurred in 3 patients, requiring no intervention. One surgery was converted to open due to bleeding, and hiatal repair performed. Wrap migration led to re-do after 10 months. The 30-day return to theatre rate was 0%, readmission rate 2% (n=1, unremarkable CT scan). One patient discharged as a day case, average stay 4 days. Out of 23 eligible patients, 15 completed post-op questionnaires, showing significant QoL improvement. Additionally, 55% no longer needed anti-reflux meds at 6-month follow-up.

Conclusions

We significantly increased the number of LARS procedures performed while meeting the national standards set by AUGIS and we observed a significant improvement in our patients' quality of life following surgery. Experienced laparoscopic Upper GI surgeons can safely and effectively offer anti-reflux surgery in a DGH setting. Our commitment to prospective data collection for audit and research purposes has been a major strength. Future objectives include further consolidation of our work and expanding the range of procedures, such as magnetic sphincter augmentation (LINX), to improve day-case rates.
OGBN P41 Cholecystostomy drain for Acute Cholecystitis and its further management: A retrospective observational study from a University Hospital
Authors: Shams Ola , Alexiadis Aris , Kanchustambam Subba , Reece-Smith Alex
Published: November 2023

Background

Acute Cholecystitis (AC) is one of the most common surgical pathologies. The gold standard treatment of AC is cholecystectomy which can be high-risk in those with poor physiological reserve or sepsis with haemodynamic instability. Therefore, percutaneous cholecystostomy (PC) can be considered as an alternative management strategy. PC has long been used with no definitive protocol for delivery or management of patient recovery. This single center study of patients who had cholecystostomy in our trust aims to create an efficient protocol for PC drains.

Methods

We conducted a retrospective observational study of patients who had cholecystostomy in the Royal Devon and Exeter Hospital between 2019 and 2023. Data from 20 patients was obtained from patient records. Severity and duration of symptoms on presentation, frailty, co-morbidities, cholecystostomy technical approach, length of stay and complications were recorded and analysed. Regarding the post-insertion period, investigations, post-cholecystostomy management plan and discharge were assessed. We conducted a literature review to compare our results to the usual practice. Data are expressed as median and results were considered to be statistically significant where p≤0.05.

Results

PC patients were high-risk candidates (median frailty score 4) with 90% being elderly (Age > 65, median age 77). The majority were septic (median WCC 17.9 and CRP 255). Upon drain insertion, median CCI (Charlson Co-morbidity Index) was 4.5. Four cholecystostomies were transhepatic ,three were transperitoneal with the rest unrecorded.Complications included displacement, leakage, and infection (Clavien Dindo 3,2).Old age was associated with more complications (p<0.006) and drain dislocation (p<0.022). Seventeen patients were discharged with drains in, one dislodged. Two patients died. Post-insertion investigations, drain duration and follow-up differed for all patients with no protocol followed. Six patients subsequently underwent cholecystectomy.

Conclusions

The management of PC and the follow-up differs from one patient to another, as there is currently no definite protocol. Old age is associated with a higher rate of complications related related to cholecystostomy. Further studies should investigate the optimal duration of the drain, timing of the tubogram, subsequent removal of the cholecystostomy drain or cholecystectomy.
HPB P03 Stereoractic ablative radiotherapy provides a safe and feasible treatment alternative for non-surgical candidates with primary hepatocellular carcinoma
Authors: Wagner Boris , Falk Stephen , Callaway Mark , Abbadi Reyad , Appanna Gautham , Rees Jonathan , Skipworth James , van Laarhoven Stijn
Published: November 2023

Background

Stereotactic ablative radiotherapy (SABR) is a highly focused radiation treatment that delivers an intense dose of radiation to a tumour whilst limiting exposure of surrounding tissues. SABR has been associated with improvement in overall survival and local control in non-surgical candidates with primary hepatocellular carcinoma (HCC). The aim of this study was to evaluate the outcomes of HCC patients treated with SABR in a tertiary referral hepatobiliary centre.

Methods

A total of 33 patients (median age 72 years {range 47-85}, 79% male) who received SABR for primary HCC liver lesions over a 2-year period between July 2020 and August 2022 were retrospectively analysed. Patient, treatment and follow-up details were obtained from online patient records and imaging.

Patients underwent SABR either due to co-morbidity precluding surgery (23/33), lack of suitable treatment alternatives (9/33) or due to patient choice (1/33). Five patients had previously undergone liver resection, eight transarterial chemoembolisation (TACE) and three microwave ablation (MWA).

Results

Table 1 shows patient demographics and treatment details of the study cohort.

Overall survival was 79% at a median follow-up of 12 months (range 3-25). A total of seven patients died at a median of 8 months post SABR (range 4-18). Only 10/33 (30%) reported toxicity including gastrointestinal upset (n=5), fatigue (n=4) and localised rib discomfort (n=3). No Grade 3/4 toxicities were reported. Of those where radiological outcomes were available, two thirds (20/30) achieved local control at the treatment site while local disease progression occurred in 10/30 (33%). Overall, 6/20 (20%) of patients developed metastatic disease.

Conclusions

These data suggest SABR is a viable, well-tolerated and potentially effective treatment for HCC in patients unsuitable for surgical therapy. Longer-term follow-up data and prospective studies, including randomised trials, are required to assess survival benefit, and optimise patient selection and dose-fractionation regimens.
HPB P07 HIDA scan utilisation and its influence on the management of patients with Gallbladder Dysmotility Disorders – A Retrospective Multicentre Cohort Study
Authors: Ali Kiren , Qazalbash Zeeshan , Nadeem Junaid , Shahzad Khan Khurram
Published: November 2023

Background

Hepatobiliary Iminodiacetic Acid (HIDA) - Cholecystokinin (CCK) and fatty meal scan is widely used in the investigation of patients with acalculour biliary-like pain as they present a significant diagnostic and management challenge to the healthcare system. This scan detects functional capacity of gallbladder in the form of gallbladder ejection fraction (GBEF). GBEF of <35% is consistent with biliary dyskinesia and >80% with hyperkinesia, a recently postulated pathology. Laparoscopic cholecystectomy (LC) remains the treatment of choice of for both the entities. We performed audit of utility of HIDA scan and interpretation of its results across three sites.

Methods

A retrospective cohort study of patents undergoing HIDA scan across three hospitals between January 2015 and December 2022. Patients with biliary pain according to ROME IV criteria of functional GI disorders were included. Electronic case notes were reviewed and demographics, laboratory results of bilirubin and ALP, radiological investigations, endoscopy result and HIDA scan result.

Results

A total of 225 patients underwent HIDA scan; median age was 42 years (IQR 34-53) and 194 (86.2%) were female. Median time form the onset of symptoms to HIDA scan was 19 months (IQR 6-24). 35 (15.5%) had GBEF <35%, 157 (69.7%) with GBEF 36-79%, and 33 (14.6 %) had GBEF ≥80. 36 patients had LC after HIDA scan: 19 (52.7%) for biliary dyskinesia, 12 (33.3%) for microlithiasis and/or biliary sludge on EUS and 5 (13.8%) had it for symptoms but normal GBEF. Histopathology of 4 patients had normal gallbladder, while 27 had chronic cholecystitis and/or cholesterosis.

Conclusions

HIDA scan is vital investigation for recurrent biliary-like pain without presence of gallstones and gallbladder dysmotility is not uncommon in this group of patients. HIDA scan should be more liberally utilised to rule out gallbladder dysmotility. Reporting method of HIDA scan should also be standardised to help interpret the results accurately.
HPB P09 A systematic review of pancreaticoduodenectomy for pancreatic cancer in randomised control trials to examine variations in operative technique
Authors: Malik Abdullah , Karki Bishow , Mahendran Balaji , Shrikhande Shailesh , Moir John , Smith Andrew , Blencowe Natalie
Published: November 2023

Background

Pancreatoduodenectomy (PD) is a complex surgical intervention comprising multiple components which, when delivered differently, can impact outcomes, introduce bias into randomised controlled trials (RCTs) and impair accurate interpretation of results. This study aimed to systematically explore and summarise variation in PD description and standardisation amongst contemporary RCTs in pancreas surgery.

Methods

Systematic literature searches for RCTs of PD were undertaken from 2020 to 2023. RCTs including robotic PD, or other types of pancreas resection (e.g. total, distal), were excluded. The technical aspects of PD were deconstructed into constituent components and steps (pre-operative considerations, before skin incision, incision, dissection, resection, haemostasis, reconstruction, insertion of adjuncts, closure and after closure) using a methodological framework. Trial reports and protocols were scrutinised to examine whether the components/steps were described, and whether (and how) adherence was assessed.

Results

Of 83 screened articles, 29 RCTs were included, reporting on 3440 patients across 16 countries (1 trial compared pre-operative interventions, 18 trials compared intra-operative interventions, and 10 trials compared post-operative interventions). Forty-one PD steps were identified. No studies described all steps and five did not describe any. Fifteen component parts were described in one RCT. Only three RCTs reported that delivery of PD was recorded and assessed, using intra-operative photographs in all cases.

Conclusions

In a contemporary series of RCTs evaluating PD, descriptions of the procedure were inadequate. Clear descriptions of PD using pre-existing methodological frameworks in future trials are warranted to improve outcomes, decrease bias and facilitate cross-RCT comparisons in systematic reviews.
HPB P11 Hepatic vein reconstruction during hepatectomy – a feasible and underused technique?
Authors: Ahuja Manish , Joshi Kunal , Coldham Chris , Dasari Bobby , Marudanayagam Ravi , Mirza Darius , Issac John , Bartlett David , Chatzizacharias Nikolaos , Sutcliffe Robert , John Roberts Keith
Published: November 2023

Background

Hepatic vein involvement can be a contraindication to resection of liver tumours. This study aimed to assess the feasibility, long term outcomes and vein patency among patients who underwent hepatic vein reconstruction during liver resections for liver tumour(s).

Methods

Retrospective analysis of patients who underwent circumferential hepatic venous reconstruction identified from a prospectively maintained database. Standard volumetric analysis was performed using software to estimate volumetry with and without hepatic venous reconstruction. Long term vein patency was established using review of available radiology.

Results

15 patients underwent 17 venous reconstructions for colorectal liver metastases (n=13), cholangiocarcinoma (n=1) and hepatocellular carcinoma (n=1). The median FLR without and with venous reconstruction were 32 (range 18.0-74.5) and 96% (range 26.9-97.7) respectively; the median increase in FLR was 34% per patient. Venous patency was 89% at a median follow-up of 25 months (Range 1-53) with 2 graft thrombosis. No patient developed PHLF.

Conclusions

Hepatic venous reconstruction during liver resection is safe and feasible. It has the potential to expand the scope of liver resection and preserve liver and venous drainage if needed in the future.
HPB P13 A Systematic Review of the Methodology Used in Nutritional Effectiveness Trials for Pancreatoduodenectomy Patients
Authors: Halle-Smith James , Krishnan Keshav , Kirupananthan Jasmin , Pathak Samir
Published: November 2023

Background

Malnutrition is highly prevalent amongst pancreatoduodenectomy (PD) patients and remains a major modifiable risk factor for postoperative morbidity and mortality. As a result, there is a need to identify optimal nutritional therapies but this has typically been difficult due to multiple methodological issues including lack of suitable control group and outcome. Therefore, the aim of this review is to report and compare the administration of different nutritional therapies as well as reporting of nutritional outcomes in randomised controlled trials (RCTs) of PD patients.

Methods

A systematic review of randomised controlled trials (RCTs) studies reporting the effect of different nutritional interventions after PD was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase and Medline databases were searched. The search identified 21 suitable studies for inclusion.

Results

There were 5 different feeding routes reported, with oral diet (14 studies, 67%) and parenteral nutrition (9 studies, 43%) being the most common. There was widespread variation in when oral diet was started, ranging between postoperative day (POD) 1 and 7. Regarding enteral tube feeding, multiple different feed types were used and feed administration was highly variable, for both rate and duration. In terms of outcome types, 17 (81%) studies reported biochemical outcomes with serum albumin being the most common (12 studies, 57%) and 12 (57%) reported anthropometric outcomes with body mass index the most common (7 studies, 33%).

Conclusions

Amongst the published RCTs investigating the effect of different nutritional routes after PD, widespread variation in the methodology was evident. This has implications for both interpretation of results and for design of future nutritional trials. Multiple biochemical and anthropometric outcomes were reported but quality of life measures, such as the SF-36 recommended by a recently published core outcome set, were not used.
HPB P15 Diagnosis of Choledocholithiasis in Risk-Stratified patients: the benefits of Magnetic Resonance Cholangiopancreatography. - A single centre retrospective cohort study
Authors: Stevenson Carla , Kee Ng Shou , Stewart Brian , Di Rollo Domenic , Mahmud Sajid , Shahzad Khan Khurram
Published: November 2023

Background

Association of Upper Gastrointestinal Surgeons (AUGIS) guidelines recommend that magnetic resonance cholangiopancreatography (MRCP) should be performed in patients with suspected gallstone disease who have deranged liver function tests (LFTs) and dilated bile ducts on ultrasound scan (USS). Early laparoscopic cholecystectomy (LC) is recommended to reduce complications of gallstone disease. Confirmation of choledocholithiasis helps guide acute management as well as operative planning. The aim of this study was to determine the probability of choledocholithiasis on MRCP of risk stratified patients.

Methods

A retrospective cohort study of adult patients who underwent MRCP in a single centre was conducted from September 2020 to September 2022. Patients being investigated for non-biliary indications (e.g. hepato-pancreato-biliary malignancies) were excluded.

Patient demographics, pre-MRCP peak LFTs, clinical indications and all radiology imaging results were analysed. Patients were risk-stratified based on modified AUGIS guidelines using hyperbilirubinemia and the presence of biliary duct dilation on USS and CT-scans as risk factors. Patients with MRCP proven choledocholithiasis were compared to those without. P value was calculated using chi-square testing. This study was registered with Clinical Quality Project (LanQIP: 14737).

Results

1,107 MRCP were identified; 97 were excluded. Median age was 65 years (IQR 50.3-75) and 625 (61.9%) were female. 677 (67%) were inpatient scans and 432 (42. 8%) were urgent. Median time for inpatient scans was 1.1 days (IQR 0.8-2.1). 739 (73.2%) patients had known gallstones. 157 (15.5%) were post-cholecystectomy. 596 (59%) had hyperbilirubinemia and 726 (71.9%) had elevated alkaline phosphatase (ALP). 38.5% of USS and 48.2% of CT scans showed dilated ducts. Overall, 276 (27.3%) MRCPs showed choledocholithiasis. Raised ALP, hyperbilirubinemia, and dilated ducts on preceding imaging were strongly predictive for choledocholithiasis on MRCP (p<0.001).

Conclusions

Our result are consistent with previously published data. We suggest that AUGIS guidelines should be used to risk stratify patients to maximise the utility of MRCP. If early LC cannot be performed, careful assessment of patient risk factors can guide the need for MRCP to determine the need for interval endoscopic retrograde cholangiopancreatography and aid pre-operative surgical planning. In centres where expertise is available, intra-operative cholangiogram can replace the need for MRCP in low-risk group.
HPB P28 Continuous glucose monitoring improves the diagnosis of insulinoma and surveillance after endoscopic ablation therapy
Authors: Thorne Rebecca , Kowal Mikolaj , Anthoney Alan , Huggett Matthew , Shapey Iestyn
Published: November 2023

Background

Insulinomas are the most common functioning pancreatic neuroendocrine tumours (PNET) and are classically diagnosed according to Whipple’s triad. The gold-standard diagnostic test (72 hour fasting glucose/C-peptide) is difficult for patients, and risks mis-diagnosing patients who only experience post-prandial symptoms. Moreover, the advent of endoscopic ablative techniques means that confirming successful treatment can be challenging when compared with surgical resection. This study aimed to investigate the value of continuous glucose monitoring (CGM) to: a) confirm the diagnosis of insulinoma; b) guide symptom management whilst awaiting definitive treatment; and c) as a surveillance tool in patients electing for non-surgical interventions.

Methods

A 61-year-old healthy male presented with post-prandial sweating, vacant episodes and reduced exercise tolerance which resolved upon consuming glucose. Computed Tomography demonstrated a 2cm exophytic hypervascular lesion in the pancreatic body, consistent with a NET, and correlated with an Octreotide avid lesion upon SPECT/CT. Overnight fasting glucose/c-peptide was not confirmatory. The target glucose range was defined as 4.0-9.9 mmol/L and critical hypoglycaemia as ≤2.9mmol/L. Data from CGM were analysed (Time in range and critical hypoglycaemia [Chi2]; glycaemic control and glycaemic variability [T-test]) during diagnosis, in the first week post-ablation, and the recovery phase beyond 3 weeks.

Results

Data from 22,008 glucose levels were analysed over a 90 day period. Time in range during diagnosis was 67.25%, 82.8% (p<0.0001) post-ablation, and 98.9% (P<0.0001) during recovery. Critical hypoglycaemia occurred in 5.2% of measurements during diagnosis, 1.9% (p<0.0001) post-ablation, and 0.1% (p<0.0001) during recovery. Glucose levels (mean [SD] mmol/L) were 4.4 (0.47) during diagnosis, 4.9 (0.29) (p=0.0001) post-ablation, and 5.7 (0.42) (p<0.0001) during recovery. Glycaemic variability (mean [SD] %CV) was 19.4 (5.09) during diagnosis, 20.17 (5.60) post-ablation (p=0.630), and 11.3 (5.53) (p<0.0001) during recovery. Temporal changes identifying post-prandial hypoglycaemia during diagnosis, and resolution during recovery, are illustrated (Figure 1).  

Conclusions

CGM has utility to accurately diagnose insulinoma when standard tests are negative, and to improve quality of life by alerting patients to life-threatening critical hypoglycaemia. As parenchymal preserving non-operative therapies increase in popularity, especially for patients with small PNETs, sensitive, reliable, and acceptable surveillance techniques are required in order to confirm treatment success and monitor for recurrence. Proactive engagement with commissioning and regulatory bodies is necessary in order to harness the potential from emerging technologies, so that PNET patients can benefit in a similar manner as those with type 1 Diabetes Mellitus.