bluuebunny/crossref_metadata_2025 huggingface dataset:
P-L07 Nematode infection mimicking Liver metastasis from previous Melanoma
Authors: Bennett Luke , Stevens Claire , Takhar Arjun
Published: December 2021

Background

Malignant melanoma is known to metastasise to the liver. In the absence of any other disease spread it is prudent to resect these lesions. This case highlights how certain pathology can masquerade as liver metastases. Here we present a case of a gentleman previously diagnosed with malignant melanoma in 2016. He had previous liver resection for metastatic disease in 2017. Surveillance MRI picked up what was assumed to be a further metastatic deposit in the right lobe of the liver. Patient underwent resection, and subsequent histological analysis has shown this to be a worm cast from a parasitic infection.

Methods

Review of the current literature reveals just one previous case of nematode infection masquerading as liver metastasis making this a very unusual and rare finding at operation. We have undertaken review of patients imaging and histopathological specimens as well as seeking expert opinion from the infectious diseases centre in London

Results

Images were reviewed in HPB MDT and the suggestion was that this was a new malignant lesion in right lobe of liver. At time of operation the lesion had slightly odd appearance on USS. Specimen was sent for histological analysis and this showed no features to suggest malignant melanoma. On further examination there appeared to be a collection of hyalinised structures suspicious for parasitic infection. The specimen was sent to Guys for further evaluation. This confirmed that this was likely a helminth nematode resulting in a necrotic liver nodule

Conclusions

This presentation is highly unusual and review of the literature demonstrates only 1 previous case to date. The differential for liver lesions is broad and nematode infection should be included. However on a background of previous liver metastases it would not be high on the differential list. It is important that we consider this in future and ensure to clarify risk factors for nematode infection, none of which this patient had. Highlights that despite advancement in imaging it is still only after surgical resection we can be sure of the aetiology.
P-L16 The Impact of Covid-19 on the Management of Primary and Metastatic Liver Cancers; A Single Centre Experience
Authors: Tweedie Adam , McCain Stephen , Mooney James , Jones Claire
Published: December 2021

Background

The Covid-19 pandemic has impacted on all aspects of health care. Surgical specialties have been affected by the impact on theatre time and space, staff re-deployments, reduced ICU capacity for non-Covid patients, and in some cases this has had a significant impact on wait time for surgery and overall surgical capacity. In our tertiary referral HPB unit, the service has been relocated to two different sites throughout the pandemic. We aimed to assess the impact of this on patients undergoing liver resection

Methods

We examined patient data for all patients undergoing liver resection in the 15 month period prior to the introduction of national lockdown, and compared this with all patients who have undergone liver resection since. We looked at total number of cases, ICU admission rates (planned vs unplanned), length of stay, case mix, histology, rates of laparoscopic vs open surgery, and length of time from completing neoadjuvant chemotherapy to surgery. Data were obtained from electronic care records and patient notes.

Results

The overall number of cases was similar (84 pre-covid vs 86 since) and basic patient demographics were unaffected. Median length of stay was the same for both groups (7 days). Colorectal metastases were the underlying pathology in the majority of cases (56/84 pre Covid, 56/86 post). Numbers of laparoscopic and laparoscopic converted to open cases were reduced in the post-Covid era, 12 prior versus four since. The median time from completion of neo-adjuvant chemotherapy to surgery was also affected, increasing from 46 to 62 days.

Conclusions

These data show some differences in patient care in the pre and post-Covid eras, in particular a lower rate of laparoscopic surgery and longer period of time between neo-adjuvant treatment and surgery. Longer follow up is required to see if these trends persist and their effect on long term survival and recurrence rates. However, despite the strains on the system there were similar numbers of patients pre and post Covid, indicating that patients are still presenting and being treated. This showed that staff responded well to the pressures of Covid, and trainee experience would have been similar
P-L17 Post-liver transplant inferior vena cava stenosis in a large volume UK centre
Authors: Spiers Harry VM , Georgiades Fanourios , Walker Ciara , Ashcroft James , Rouhani Foad , Gibbs Paul
Published: December 2021

Background

Inferior vena cava stenosis (IVCS) is a rare complication of liver transplantation with a reported incidence rate of 3%. Limited clinical consensus exists on the management of IVCS. We report the management and outcomes of patients with IVCS at our transplant centre. 

Methods

Relevant data were collected from adult patients who underwent liver transplantation at our centre between October 2014 and August 2020. These included demographics, investigation and management details with regards to IVCS. Values presented as % of total and median with interquartile range (IQR). 

Results

A total of 636 liver transplants were performed during the study period, of which 48 (7.6%) patients were investigated for possible IVCS. Of those, 14 (2.2% of total) were found to have IVCS, 85.7% (n = 12) were female. Only 2/14 were re-transplants and pre-transplant portal vein thrombus was present in 3 cases (21.4%). 10 livers (71.4%) were DBD donors. Normothermic machine perfusion was used in 4/14 patients. All 14 recipients found to have IVCS had had an implantation using a modified piggyback cavocavostomy technique. The IVCS was identified at a median of 25.5 days (19.7-30.8 days) following transplantation within the suprahepatic IVC in 92.9% (n = 13). Hemi-azygos collateralisation was seen in 4 cases (28.6%). 8 of the 14 recipients underwent intervention for IVCS, 6 patients were managed with balloon venoplasty, 1 patient required an IVC stent and 1 was managed surgically. Six of the recipients with IVCS died, 4 of whom had an intervention for their stenosis and 3 of these were within 90 days of their transplant. Pressures measured at the anastomotic stricture were higher in those who succumbed (median of 21 Vs 12.5 mmHg; p=.017). 

Conclusions

At our centre, cava-replacement technique was not associated with IVCS. Patients with more significant strictures (as evidenced by higher pressures at the anastomotic stenosis) may have an increased mortality risk.
P-O02 Management Experiences of Post-gastrectomy Severe Alkaline Reflux Oesophagitis
Authors: Phoenix Eimear , Temperley Hugo , Donlon Noel , Donohoe Claire
Published: December 2021

Background

Alkaline reflux oeosphagitis is a recognized complication of procedures that compromise the lower oesophageal sphincter (LES), including gastrectomy. Incidence of reflux is dependent on the reconstructive procedure with Roux-en-Y esophagojejunostomy commonly accepted as the optimal method. The authors report their experience of 6 patients who underwent remedial intervention for severe alkaline reflux esophagitis following gastric surgery.  

Methods

A retrospective review of 6 patients who had underwent a previous gastric procedure and developed symptoms of gastroesophageal reflux disease, over a 6-year period (2014-2020). Reflux symptoms were diagnosed by clinical history, radiology, endoscopy and esophageal manometry prior to proceeding to surgical reflux control. Post-operative outcomes following anti-reflux surgery were assessed by means of serial outpatient assessments and endoscopy. 

Results

Six patients were included in this report, 4 males and 2 females with an average age of 73 years (range 58-91). Primary diagnoses encompassed; 4 gastric adenocarcinomas, 1 gastric neuroendocrine tumour and 1 patient with debilitating gastric antral vascular ectasia (GAVE) syndrome. Four patients underwent total gastrectomy and 2 subtotal gastrectomy with Roux-en-Y reconstruction. Onset of post-operative reflux symptoms ranged from 2-weeks to 3-years. Failing medical management, all patients underwent jejunojejunal anastomosis and Roux limb length revision with surgical jejunostomy. At follow up 5 patients had some degree of symptom resolution; 3 complete resolution, 2 initial resolution and 1 with unresolved symptoms.

Conclusions

Severe alkaline reflux oesophagitis is a recognized complication of gastric procedures compromising the LES. The authors report our experience of managing this complication following gastrectomy with jejunojejunal anastomosis and Roux limb length revision, with a majority of patients having improvement in if not complete resolution of reflux symptoms.
P-O14 The predictive role of pre-operative liver function tests in outcomes following emergency appendicectomy
Authors: Khan Khurram , Galbraith Norman , Gall Lewis , Macdonald Andrew
Published: December 2021

Background

Acute appendicitis remains one of the most common diagnoses in emergency general surgery, with recent evidence from the COMMA trial confirming that appendicectomy is the cornerstone of definitive management in most patients. With a wide range of severity and of patient physiology, complications are a burden to patients and the health service. We hypothesised that liver function tests have predictive value for complications following emergency appendicectomy.

Methods

A multicentre retrospective observational study was carried out across 4 hospitals (2 teaching centres and 2 district general hospitals) for adult patients who underwent emergency appendectomy between August 2018 and November 2020.  Patients were identified through pathology records and data was extracted from electronic case records for patient demographics, pre-operative routine laboratory results, operative details, and clinical outcomes. Peak perioperative liver function parameters were analysed using unpaired two-way T-tests, Pearson’s correlation coefficient, ANOVA and multivariate regression to determine their relationship with conversion to open surgery, superficial and deep surgical site infection (SSI), length of stay (LOS) and 30-day re-admission rates.

Results

Of 1131 patients included, 57.4% were male, 80.5% were laparoscopic, with 7.3% converted to open, 10.8% performed open, and 1.5% by laparotomy. Mean LOS was 3.81 (SD4.0) days, 6.3% readmission rate, with 2.3% superficial SSI and 5.0% deep SSI.

ALP was higher in patients with superficial SSI (p < 0.001). Lower ALT was associated with wound dehiscence (p < 0.001). Bilirubin, AST and ALT were lower in patients with chest infections (p < 0.001). ALP correlated with increased LOS (p < 0.001).

On multivariable regression, ALP was associated with superficial SSI (p < 0.001), and LOS (p < 0.001). ROC curve analysis demonstrated AUC of 0.655 for ALP and superficial SSI.

Conclusions

Emergency appendicectomy is completed laparoscopically in more than 80% of patients and complication rates are acceptable. Routine liver function tests were associated with important clinical outcomes including superficial SSI, wound dehiscence, chest infection, LOS and readmission rate. Patients who had superficial SSI, wound dehiscence, chest infection and readmission with 30 days had lower transaminase levels compared with those with uncomplicated recovery.
P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic
Authors: Ghassemi Nader , Meilak Joseph , McKay Siobhan C , Bhatt Anand , Durkin Damien , Athwal Tejinderjit
Published: December 2021

Background

During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks.  Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%.  However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies.  During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely.

Methods

Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery.  Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities.  Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests.  We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality.  Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020.

Results

There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients.

Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP.

Conclusions

The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies.  This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.
P-OGC02 The development of an evidence based algorithm for the provision of nutrition as part of an Enhanced Recover After Surgery (ERAS) pathway in patients undergoing elective Gastrectomy and Oesophagogastrectomy for cancer
Authors: Dossou Vida , Cleary Ally
Published: December 2021

Background

Following a recent merger or UGI Cancer services, a consensus was needed for the ERAS pathway nutritional elements. ERAS is a way to maintain physiological function following surgery enabling post-operative recovery without adversely affecting morbidity or mortality. 

It is a coordinated pathway that enables consistent, evidence based multi-modal care. Anaesthesia, nutrition, analgesia, surgical technique and physiotherapy are active and key components of enhanced recovery along with patient involvement and empowerment. 

ERAS in UGI revealed a significant reduction in LOS in most cases, by around 50% without increasing morbidity and mortality when compared to standard post-operative care. 

Methods

Coupling the service redesign with the publication of guidelines in ERAS and Gastrectomy, it was decided to review the evidence base for ERAS and nutrition support specific to UGI Cancer surgery. 

In addition to this, aim to review the evidence for and against the use of immunonutrition (IN). 

Literature searches were conducted using CINAHL and PUBMED databases. The evidence was critiqued and a consensus reached. From this evidence review, an algorithm recommending the instigation of nutrition post Upper Gastrointestinal (UGI) surgery as part of an ERAS pathway was developed. 

Results

An algorithm was produced standardising the nutritional care for patients undergoing elective UGI surgery in our centre, which formed part of the ERAS care pathway produced through the ERAS steering group. All patients were screened for risk of malnutrition at the start of their surgical care pathway and regularly throughout their journey, appropriate nutritional support will be provided by a specialist Dietitian to optimise the patient.  

Conclusions

The evidence to support the use of IN is conflicting and is not currently recommended on this ERAS pathway.

Nutritional intake in the form of Oral Nutritional Support (ONS) in subtotal gastrectomy can be commenced at Day 2.

Nutritional intake in the form of ONS in Total Gastrectomy can be commenced at Day 4.

Nutritional intake in the form of ONS in Oesophagogastrectomy can be commenced at Day 5.

After ONS tolerated without clinical symptoms, patient can be progressed to Soups, Jellies, Ice creams for 24 hours then to an UGI specific soft menu pre discharge.
P-OGC06 The effect of surgical complications on long-term prognosis following oesophagectomy for oesophageal cancer
Authors: Broadbent Anna , Rahman Saqib , Grace Ben , Walker Robert , Noble Fergus , Kelly Jamie , Byrne James , Underwood Timothy
Published: December 2021

Background

Globally, oesophageal cancer incidence continues to increase. In recent years, surgical and oncological advancements have increased survival rates. Despite this, survival remains <50% at five-years for patients treated with curative oesophagectomy. Previous data has suggested post-operative complications may play a role in long-term increased mortality in oesophageal cancer patients. This study aimed to examine the effect of adverse in-hospital events following oesophagectomy on the long-term prognosis for oesophageal cancer, including assessing the effect of cumulative complication burden using data from a single high-volume academic unit in the UK. 

Methods

Retrospective analysis of patients undergoing oesophagectomy for oesophageal adenocarcinoma or squamous cell carcinoma was performed to assess the relationship between in-hospital events and long-term survival. Analysis was limited to patients who survived to 90 days post-oesophagectomy (n = 380). Complications were graded according to the Clavien-Dindo (CD) classification and the Comprehensive Complication Index (CCI). Survival was estimated using Kaplan Meier survival curves and multivariate cox-regression, adjusting for variables known to influence survival. The absolute magnitude of effect of complications on survival was assessed using the risk-adjusted population attributable fraction (PAF), which estimates the percentage improvement in survival if specified complications were removed.

Results

Complications occurred in 251 patients (66.1%). ≥CD3a complications (HR1.65, 95%CI 1.15-2.38, p < 0.010) and unplanned critical care admissions (HR2.24, 95%CI 1.45-3.46, p < 0.001) were independently associated with worse prognosis whereas pulmonary complications and anastomotic leak were not. A CCI >30 was the optimum cut-point for OS (HR1.94, 95%CI 1.36-2.78, p < 0.001), and after weighting to remove confounding bias median survival was shorter with CCI>30 (28vs72 months, p < 0.001).  There was no difference in median survival when CCI>30 occurred from major or multiple minor complications (31 vs 21 months, p = 0.096). The risk adjusted PAF for CCI>30 was 8.5% (95%CI 3.6-13.1%).

Conclusions

Long-term survival following oesophagectomy for oesophageal cancer is significantly affected by major complications and unplanned critical care admissions. The cumulative effect of multiple post-operative minor complications is comparable to the effect of major complications on long-term survival from oesophageal cancer, and cause a substantial number of potentially preventable deaths, even in patients who survive to discharge.
P-OGC09 Evaluating the Availability of Services for Cancer Patients Following Surgical Resection of Esophago-Gastric Tumours
Authors: Al-Housni Ragad , Gossage James
Published: December 2021

Background

Upper gastrointestinal (UGI) cancers account for 11% of cancers in the UK, with oesophago-gastric cancers having the highest incidence rate in males. Since publication of the NHS Cancer Plan in 2001, mortality rates of oesophago-gastric cancer patients following curative surgery have been decreasing, causing an increased demand for services, particularly during follow-up post-operatively. Current guidelines recommend that patients are treated by specialised multi-disciplinary teams, involving both cancer nurse specialists and dieticians. However, the integration of these workers into patient care is still ongoing in UGI, with no national recommendations for trusts on the minimum requirements needed to run adequate services.

Methods

This was a retrospective observational study from October 2020 to April 2021. Cancer nurse specialists from all cancer trusts in England and Wales carrying out surgical resection of oesophago-gastric tumours were identified and contacted to complete a survey. The survey was divided into 4 main themes: the organisational setup of the trust, the follow-up of patients, the dietetic input and post-operative symptoms and survivorship.

Results

A total of 12 trusts out of 38 returned a completed survey. Differences were observed in the number of CNSs and UGI dieticians available across trusts. 50% of responders felt that the number of CNSs at their trust was not adequate to run efficient services for patients. In 42% of cases, the CNS was solely responsible for long-term follow-up of patients, up to 5-years in the majority of trusts. 11 trusts routinely follow-up patients with a dietician, integrated into MDT clinics. 75% of trusts had an associated patient group that could provide additional support to patients.

Conclusions

Differences in the availabilities of services and staff for oesophago-gastric cancer patients are present across trusts in England, which can lead to inequalities in patient care. Further longitudinal studies are needed to evaluate the impact of these differences on patient surgical outcomes and mortality.
P-OGC16 Minimally Invasive Oesophagectomy: Technique and learning curve over 10 years
Authors: May-Miller Peter , MacKenzie Hugh , Jenkins Nick , Mercer Stuart , Carter Nick , van Boxel Gijs , Knight Ben
Published: December 2021

Background

The use of minimally invasive oesophagectomy (MIO) in the treatment of patients with oesophageal malignancy has developed since its first description by Cuschieri in 1992, although mainstream uptake of this technique has not been forthcoming. Oncological resection margins were not compromised in MIO, whilst complications and two-year mortality rates improved in MIO compared to open oesophagectomy. The advantages of MIO compared to open surgery include the speed of recovery, improved return to baseline quality of life, better physical function and less pain. We present our experience of MIO including operative technique, tips, and learning curve.

Methods

160 patients underwent MIO at Portsmouth Hospitals University NHS Trust between August 2010 and December 2019. After June 2016 there was a significant change in surgical technique and pathway as outlined below and this time point has been interrogated.

Primary outcomes were operative duration (minutes) and both 30-day and in-hospital mortality. Secondary outcomes were length of in hospital stay (days), ITU stay, conversion to open surgery and complications.

We undertake laparoscopic abdominal phase and thoracoscopic or robotic assisted thoracic phase oeasophagectomy. Dual consultant operating is standard; and we work consistently with the same group of anaesthetists and theatre staff.

Results

82.5% of our 160 patients were male, median age was 67 years. Operative duration showed a steep learning curve over the first 10 cases followed by stabilisation to case 56 and then improvement. CUSUM analysis of the anastomotic leaks showed a change point at 53 cases - 30.8% vs 16.7% (p = 0.05). 30-day mortality is 1.88% and median length of stay 12 days (IQR12.75). Complications of Clavien-Dindo ≥III occurred in 35% and “perfect” outcomes in 21.25%. Conversion to open in 5.6% of cases but only 1 in the last 100 patients.

Conclusions

There is a learning curve associated with the adoption of a new technique. MIO can be performed safely and cost effectively with equivalent oncological outcomes with the advantage of improved quality of life. Oesophageal cancer is still poorly understood and we therefore must spend more thought on how best to give our patients good quality disease free life. Our outcome data is within existing published data and our prospectively collected data is thorough and meticulous. Though some complications are inevitable, small changes lead to marginal gains and add up to better outcomes.
P-OGC21 Patient perspectives on symptoms of importance and preferences for follow-up after major upper gastro-intestinal cancer surgery
Authors: Pucher Philip , Coombes Annie , Evans Orla , Taylor Joanna , Moore Jonathan , White Annabelle , Lagergren Jesper , Baker Cara , Kelly Mark , Kelly Mark , Gossage James , Dunn Jason , Zeki Sebastian , Byrne Ben , Andreyev Jervoise , Davies Andrew
Published: December 2021

Background

Long-lasting symptoms and reductions in quality of life are common after oesophago-gastric surgery. Post-operative follow-up has traditionally focussed on tumour recurrence and survival, but there is a growing need to also identify and treat functional sequelae to improve patients’ recovery.

Methods

An electronic survey was circulated via a British national charity for patients undergoing oesophago-gastric surgery and their families. Patients were asked about post-operative symptoms they deemed important to their quality of life, as well as satisfaction and preferences for post-operative follow-up.   Differences between satisfied and dissatisfied patients with reference to follow-up were assessed.

Results

Among 362 respondents with a median follow-up of 58 months since surgery (range 3-412), 36 different symptoms were reported as being important to recovery and quality of life after surgery, with a median 13 symptoms per patient. Most (84%) respondents indicated satisfaction with follow-up. Unsatisfied patients were more likely to have received shorter follow-up than 5 years  (27% among unsatisfied patient vs. 60% among satisfied patients, p < 0.001and were less likely to have seen a dietitian as part of routine follow-up (37% vs. 58%, p = 0.005).

Conclusions

This patient survey highlights preferences with regard to follow-up after oesophago-gastrectomy. Longer follow-up and dietician involvement improved patient satisfaction. Patients reported being concerned by a large number of gastrointestinal and non-gastrointestinal symptoms, highlighting the need for multidisciplinary input and a consensus on how to manage the poly-symptomatic patient.
P-OGC34 Pandemic paradigms: Early outcomes of radical chemoradiotherapy for patients with operable oesophageal and oesophago-gastric junctional adenocarcinoma
Authors: Rupasinghe Sukitha Namal , Ninkovic-Hall George , Mckinney Rachel , Howes Nathan , Rao Rohith , Gunasekera Rohan , Grocock Christopher , Hartley Mark , Kaul Anil , Javed Muhammad Shafiq , Stephens Nathan
Published: December 2021

Background

The peak waves of the COVID pandemic necessitated a paradigm shift in surgical management of patients with oesophageal adenocarcinoma due to both pressure on services and high mortality rates for those with COVID undergoing surgery. The Association of Upper GI Surgeons (AUGIS) guidance on treating Upper gastrointestinal cancers in the COVID era made suggestions to treat operable adenocarcinomas using definitive/consolidation chemoradiation (DCRT) over standard neo-adjuvant chemotherapy (NAC) and our unit altered practice accordingly for a cohort of patients. For affected patients we monitored and audited clinical outcomes and the initial results from this are presented here.

Methods

Patients with oesophageal or oesophago-gastric junctional (O/OGJ) adenocarcinoma with potentially curative disease where initial management was altered from a treatment path which would have included surgery (with or without neoadjuvant therapy) to DCRT discussed at our regional multidisciplinary team (MDT) meeting between 1st February-1st June 2020 were included. Patient demographics, investigations, treatment given and clinical outcomes were prospectively recorded.  

Results

31 Patients with operable adenocarcinoma of O/OGJ had treatment altered to DCRT (mean age 65.4, [range 43 – 79]), 28 (90%) Male. 1 patient deteriorated prior to starting, leaving 30 who completed DCRT.  Of these 4 patients had already had NAC prior to DCRT. 

Follow up was for a median of 8 (range 4-8) months following start of treatment.

Post- vs pre-treatment FDG-PET imaging demonstrated a significant reduction in the mean maximum standardized uptake value (SUVmax) (p = 0.003, Sign test), in all but 3 patients. 

11 patients had DCRT alone, (all alive at the time of data collection), of whom 3 patients had no sign of tumour.

19 (56%) patients proceeded to salvage oesophagectomy at a median of 15(range 10-25) weeks after completion of DCRT. 42% of these patients had a complete pathological response to treatment. There was a 5% perioperative mortality rate for this group and 1 patient was found to be unresectable on the day of surgery.

At the time the data was reviewed overall survival of the entire cohort was 91%, 56% of whom had no sign of residual or recurrent disease.

Conclusions

A disease free survival of 56% compares poorly with the literature at the 3-month interval. The long-term follow-up of these patients will only be apparent in the coming months and years. This data does not support the use of this modality in the future and alternate treatment plans should be devised for future pandemics.
P-OGC36 Staging Laparoscopy in Oesophago-gastric cancers; A highly selective approach and its impact on patient outcome during COVID 19
Authors: Koroma Paul , Chaudhury Madhu , Ali Raza Shehrazi S , Ball Christopher , Turner Paul , Ward Jeremy , Pursnani Kishore , Shetty Vinutha
Published: December 2021

Background

Staging laparoscopy is performed in all Oesophago-gastric cancer patients suitable for radical treatment with tumour staged ≥T2 prior to neoadjuvant chemotherapy. In response to COVID 19 pandemic, on 25th March 2020, the joint statement issued by the Royal College of Surgeons and AUGIS advised all laparoscopic procedures should be avoided due to the risk of virus transmission associated with aerosol-generating procedures. In accordance with the guidance, a more selective approach on who underwent a staging laparoscopy was followed. This audit explores its impact on patient outcome comparing data from pre COVID period with the COVID period.

Methods

Retrospective and prospective data was collected for 24months on all OG cancer patients from 25th March2019 to 24th March2021. ‘Pre COVID’ period was defined as 25th March 2019 to 24th March 2020 and ‘COVID’ period was defined as 25th March 2020 to 24th March 2021. All patients with Oesophago-gastric cancer with MDT cancer staged ≥T2, suitable for neoadjuvant chemotherapy were included. Patients with tumour staged <T2 and or diagnosed with squamous cell carcinoma involving upper or middle third of oesophagus were excluded. Fishers Exact model using SPSS V24 was used to identify any statistically significant differences between the 2 groups.

Results

Pre-COVID Period: 80patients underwent staging laparoscopy. Of these, 9patients(11.6%) with tumour staged as ≥T3 were declined curative surgery due to advanced disease(n = 2), metastatic disease(n = 3) or both(n = 4). In total, 40patients underwent curative surgery and there were 0 open/close laparotomies.

COVID Period: Of the 79patients suitable for staging laparoscopy, only 7patients(8.7%) underwent laparoscopy. Of these, 3patients(3.8%) with tumour staged as ≥T3 were declined curative surgery due to advanced disease(n = 2) and metastatic disease(n = 1). In total, 33patients underwent curative surgery and only 1patient had an open/close laparotomy due to a liver metastases. No statistically significant difference was found p = 0.0913

Conclusions

Staging laparoscopy is a useful tool for accurate staging of Oesophago-gastric cancers. It helps avoid unnecessary open and close laparotomy due to advanced disease and also allows us to assess patient fitness to major surgery. During the pandemic, the number of staging laparoscopies performed declined significantly but with no statistically significant difference to patient outcome. Thus we conclude,  the COVID 19 pandemic has enabled us to have a selective approach to performing staging laparoscopy in Oesophago-gastric patients with advanced disease staged ≥T3 only.
P-OGC45 Could lymphatic, vascular or perineural invasion status improve clinical staging prior to oesophagectomy?
Authors: Chmelo Jakub , Hardy Kiera , Brown Joshua , Prasad Pooja , Phillips Alexander W
Published: December 2021

Background

Unimodal treatment of oesophagogastric cancer (OGC) with surgery only is currently reserved for patients with early disease. Presence of vascular (VI), perineural (PNI) or lymphatic vessel invasion (LI) in pathological samples have been shown to be negative prognostic indicators of survival. These factors have been found to be associated with more advanced disease. Staging of OGC has limitations and in neoadjuvant naive populations it has been shown to be imperfect. It is unknown whether VI, PNI or LI could play any role during the staging process.

Methods

Patients with early disease (cT2 or less and cN0) who underwent unimodal treatment of their oesophageal or junctional cancer with oesophagectomy between 2010 and 2019 in a single centre were included in this study. Therelationship between presence of LI, VI and PNI on pathological samples with incorrect staging/upstaging indicating locally advanced disease (defined as pT3+ or pN+) was studied using logistic regression model.  

Results

There were 128 patients included. 26 patients (20%) were upstaged to pT3+ or pN+. LI, VI and PNI were present in 18%, 11% and 8% respectively. The presence of LI and clinical T stage were independently predictive of incorrect staging/upstaging in multivariable logistic regression analysis. LI (OR 12.5 95%CI 3.7-42.8, p < 0.001) and cT2 (OR 5.9 95%CI 1.5-23.2, p = 0.01).  

Conclusions

These results indicate that the presence of LI from pathological samples is a strong independent prognostic factor of incorrect staging which would normally favour neoadjuvant treatment. The presence of LI suggests aggressive disease. Further studies should concentrate on the possibility of obtaining LI status from preoperative biopsies or endoscopic mucosal resection samples. This staging information could play an important role in deciding whether neoadjuvant therapy is indicated in patients staged as early disease.
P-OGC48 Definitive Chemoradiotherapy versus Neoadjuvant Chemoradiotherapy Followed by Radical Surgery for Locally Advanced Esophageal Squamous Cell Carcinoma: Systematic Review and Meta-analysis
Authors: Kamarajah Sivesh K , Evans Richard , Gossage James , Griffiths Ewen , Pucher Phil
Published: December 2021

Background

Debate exists surrounding definitive chemoradiotherapy (dCRT) over neoadjuvant chemoradiotherapy and surgery (nCRS) as a primary treatment for esophageal squamous cell carcinoma (ESCC) owing to the heterogeneity in the quality of current evidence. This study aimed to compare long-term survival of dCRT with nCRT for ESCC from high-quality studies.

Methods

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 23rd July 2021. Primary outcome was overall survival (OS) and secondary outcomes were disease-free survival (DFS) and recurrence rates. A meta-analysis was conducted using random-effects modelling to determine pooled adjusted multivariable hazard ratios (HRs).

Results

This review included ten high-quality studies including 14,092 patients, of which 30% received nCRT. Three studies were randomized controlled trials (RCT), six studies were single-center. dCRT and nCRT regimens were reported in six studies and surgical quality control were reported in two studies. Outcomes for OS and DFS were reported in eight and three studies, respectively. nCRT had significantly longer OS (HR: 0.68, CI95%: 0.54 - 0.87, p < 0.001) and DFS (HR: 0.50, CI95%: 0.36 - 0.70, p < 0.001) than dCRT.

Conclusions

nCRS followed by planned esophagectomy appears to remain the optimum curative treatment regime in patients with loco-regional ESCC. Thus, surgery remains an integral component of the management of patients with ESCC. As adjuvant and immunotherapy treatment regimens develop, ongoing prospective assessment of the role of radiotherapy in combination with modern treatment modalities should be studied
P-OGC54 Economic cost utility analysis of stage directed oesophageal adenocarcinoma treatment
Authors: Robinson David , Powell Arfon , Lewis Wyn
Published: December 2021

Background

Oesophageal Cancer (OC) treatment levies substantial financial burden on Health Services and Best Supportive Care (BSC) outcomes are poor. Potentially Curative Surgery with or without Chemotherapy is offered to patients with locally advanced disease and this study aimed to examine treatment costs related to life-years gained in patients having potentially curative treatment (oesophagectomy) and those receiving Best Supportive Care (BSC).

Methods

Consecutive 179 patients diagnosed with potentially curative adenocarcinoma of the oesophagus between 2010 and 2017 were classified according to treatment modality by intention to treat (surgery vs. neoadjuvant/adjuvant chemotherapy). Cost calculations for one-year’s treatment from referral were made according to network diagnostic, staging, and treatment algorithms. Primary outcome was Overall Survival (OS).

Results

OC median survival after BSC is reported to be 3 months costing £4391 compared with Oesophagectomy median survival (all stages) of 44 months costing an average of £26,652 for one year’s treatment: BSC cost per QALY £92,448 compared with £12,207.20 for potentially curative surgery. Cost incurred for stage I OC was £25,153.09, stage II £26,795.17, stage III £28,781.81, and stage IV £28,592.64. Based on these values, the cost per Quality Adjusted Life Year (QALY) for stage I OC was - £8,361, II - £12,319, III - £21,998 IV - £35,011.

Conclusions

Potentially curative treatment that included oesophagectomy improved OS fifteen-fold compared with BSC and was cost effective at national thresholds of readiness to pay per QALY.
P-OGC60 Predicting the risk of venous thromboembolism during neoadjuvant therapy for oesophagogastric cancer
Authors: Calabrese Michele , Chmelo Jakub , Prasad Pooja , Brown Joshua , Wallace Lauren , Phillips Alexander
Published: December 2021

Background

Locally advanced oesophageal cancer is usually treated with neoadjuvant treatment (NAT) followed by surgery. Venous thromboembolism (VTE) is a recognised complication in these patients. Those who develop VTE may have an inferior vena cava filter placed prior to surgery to reduce the risk of further complications. This study aimed to identify specific risks for VTE during (NAT) for oesophagogastric cancer (OGC) and whether this increases postoperative morbidity.

Methods

Patients undergoing NAT for OGC followed by surgery at a single high-volume centre between January 2015 and June 2020 were identified from a prospectively maintained database. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors for the development of VTE as well as the association between diagnosis of VTE and morbidity.

Results

The incidence of VTE in this cohort was 6.7% (27/406). Independent risk factors for developing VTE in multivariable analysis were BMI – OR 1.093 (p = 0.045) and age – OR 1.067 (p = 0.019). Type of chemo(radio)therapy regimen used, pT, pN stage, previous history of ischaemic heart disease or being an active smoker at diagnosis was not associated with VTE occurrence. Diagnosis of VTE during neoadjuvant treatment was not associated with a higher risk of developing a serious postoperative complication (Clavien-Dindo grade III and above) (p = 0.699).

Conclusions

Patients with a raised BMI or older age are at higher risk of developing VTE during NAT for OGC. These patients must be appropriately counseled on the higher risk of VTE prior to commencing NAT. However, the development of a VTE does not appear to confer any additional post-operative complication risk.
P-OGC65 Patterns and timing of recurrence following resection of oesophago-gastric adenocarcinoma
Authors: Shen William , Craig Carol , MacDonald Andrew , MacKay Colin , Forshaw Matthew , Dreyer Stephan
Published: December 2021

Background

Recurrence following resection of oesophago-gastric adenocarcinoma (OGA) is frequent and associated with poor outcomes. Predictors of site, timing and mechanisms driving recurrence is poorly defined, which limits the development of anti-metastatic agents. The aim of this study was to investigate the patterns and timing of recurrence following resection of OGA.

Methods

Retrospective review of a prospectively maintained resection database from the Glasgow Royal Infirmary oesophago-gastric unit of patients undergoing surgery for OGA. Primary outcomes were recurrence and cancer specific death following surgery. Recurrence patterns were defined as liver, lung, peritoneal, locoregional only and other distant groups. The latter is a heterogenous group that do not include any liver, lung, or peritoneal metastases. 

Results

N = 635 patients were identified having undergone surgical resection of OGA. Of these, n = 262 developed confirmed recurrent disease. Liver metastases (n = 86, 33%) were the most common site of recurrence, followed by peritoneal (n = 35, 13%), lung (n = 33, 13%) locoregional only (n = 51, 20%) and other distant sites (n = 57, 22%). Liver recurrence was associated with significantly worse disease specific (19.1 vs 28.2 months, P < 0.001) and recurrence free survival (P = 0.006). There was no association between site of recurrence and known prognostic clinicopathological factors, including anaerobic threshold (P = 0.810), nodal status (P = 0.088), pathological T-stage (P = 0.357), differentiation (P = 0.195), deprivation index (P = 0.996), perineural (P = 0.475) or lymphovascular (P = 0.422) invasion.

Conclusions

Liver metastases is the most common site of recurrence following surgery for OGA. Prognostic clinical and pathological factors do not determine the site of recurrence, suggesting that molecular features of the primary tumour determine and promotes recurrence patterns. Further study to delineate the molecular and microenvironment factors driving recurrence patterns is urgently required.
P-OGC72 Morbidity following oesophagectomy: the long-term re-operation rate after surgical resection in a Scottish tertiary centre
Authors: Chien Siobhan , Gall Lewis , Khan Khurram , Macdonald Andrew , Craig Carol , MacKay Colin , Forshaw Matthew
Published: December 2021

Background

Oesophagectomy remains the best curative option for early stage or locally advanced cancers of the oesophagus and gastro-oesophageal junction. The long-term morbidity associated with oesophagectomy is poorly understood. This study aimed to describe re-operation rates for oesophagectomy-related complications, performed beyond 90 days from index oesophagectomy.

Methods

A retrospective cohort study of all oesophagectomies performed in a single tertiary centre between 01 January 2010 and 31 December 2019 was performed. Electronic records were interrogated and patients dichotomised into two groups, with patients that underwent re-operation at ≥ 90 days after oesophagectomy for complications directly related to the index procedure compared to patients who did not have further surgery. All endoscopic interventions were excluded from analysis. The median length of follow-up was 34 months (IQR 20-67).

Results

343 patients were eligible for analysis. Patient demographics and index operative approach were similar between the two groups. Beyond 90 days from surgery, 8.7% of patients (30/343) required a further operation for complications directly related to oesophagectomy. The median time to re-operation was 15.5 months (IQR 12-29). 28 out of a total of 38 re-operations performed (73.7%) were for wound complications (including 15 incisional hernia repairs and 7 excision of stitch sinus). Development of a wound infection in the immediate post-operative period was associated with an increased rate of later re-operation (16.7% vs. 4.8%, p = 0.022).

Conclusions

A small but significant number of patients require re-operation following oesophagectomy beyond 90 days of surgery. This should form part of the pre-operative informed consent discussion in order to fully appraise patients and manage expectations. Reducing the incidence of early wound infection appears to be a key factor.
P-OGC76 A patient engagement event to assess feasibility of preoperative enhanced recovery groups in patients with oesophagogastric cancer undergoing surgery
Authors: Jarvis Emma , Evans Orla , Mundle Georgia , Noor Zainab
Published: December 2021

Background

Enhanced recovery (ER) includes pre-operative counselling during individual patient consultations with multidisciplinary team (MDT) members. Patients can experience lengthy appointments seeing multiple professionals. This negatively impacts on their ability to retain and process information, and results in long, overrunning clinics. Separate, virtual ER group sessions have been proposed to deliver aspects of the pre-operative appointment which are common to all patients undergoing oesophagogastric (OG) cancer surgery.  The aim is to improve patient engagement and experience, and improve efficiency of clinics. A patient engagement event was undertaken to gain feedback from patients about the existing service and the proposed virtual group.   

Methods

A semi-structured telephone interview was developed with the support of a Patient & Public Engagement Team. The 30 minute interview covered aspects such as patient experience of ER information delivery, the quality of the information they received and their thoughts on attending virtual group sessions. Seventy patients, who had undergone surgery for OG cancer in the previous 14 months were invited to take part.  A Health Informatics Team screened the patient list prior to invitation letters being sent. The telephone interviews took place in November 2020. 

Results

Twenty-seven patients responded (37%). Of these, 89% felt they received all information required for surgery preparation. Over 50% reported receiving adequate information to support with common post-operative issues (dietary - 81%; physical activity - 55%) but would like more on others (psychological impact - 26%). Patients highlighted that the MDT clinic took many hours and information delivery was overwhelming.

The internet was accessible to 85% and 56% thought the information provided prior to surgery could have been delivered in a virtual group. Patient perceived advantages to virtual groups included: peer support; reduced travel; and avoidance of information repetition and overload. 

Conclusions

Patient preference, perspective and needs are paramount when designing healthcare services. Results from this patient engagement event suggest that the delivery of preoperative information and counselling as part of ER could be improved through the implementation of virtual ER groups. They also suggest that most patients perceive benefits to such a model, including the addition of peer support. The next steps in the proof of concept are to develop the virtual groups MDT content and pilot in a cohort of patients, evaluating patient related outcome measures and impact on service efficiency.