bluuebunny/crossref_metadata_2025 huggingface dataset:
HPB P21 Surgery for peri-hilar cholangiocarcinoma: The Liverpool hepatobiliary unit experience
Authors: Gilbert Timothy , Bird Nicholas , Quinn Marc , Diaz-Nieto Rafael , Jones Robert , Fenwick Stephen , Malik Hassan
Published: December 2022

Background

Surgery for perihilar cholangiocarcinoma (pCCA) offers the only possibility of long-term survival but remains a formidable undertaking associated with significant post-operative morbidity and mortality. We aim to share our experience of managing these complex patients within a high-volume UK centre.

Methods

A retrospective review of a prospectively maintained database was performed on all patients who underwent resection for pCCA at our unit between 2009–2021. Kaplan–Meier analysis was used to estimate overall and disease-free survival (OS/DFS). Post-op complications were graded using the Clavien-dindo classification and reported as minor (Grade1/2) or major complications (Grade3/4).

Results

102 patients underwent surgery for pCCA at our unit between 2009–2021. The majority of patients required pre-operative biliary drainage via ERCP and metal stent insertion. Following MDT and CPEX assessment eligible patients underwent an initial staging laparoscopy followed by curative resection. 30% of patients required a PVE to increase the proposed functional liver remnant volume prior to surgery. The majority of patients (76%) had Bismuth-Corlette IIIA/B or IV disease necessitating a major liver resection along with radical bile-duct resection. Post-op morbidity rates were high with 42% experiencing a major (grade3/4) complication. Of these patients 14 individuals subsequently died culminating in a 90-day mortality rate of 13.7%. Median LOS was 11 days (IQR 5–59). Median OS for the entire cohort was 36.3 months (CI:26.7–45.8) with a nominal 5-year survival rate of 34.6%. 40% of patients received adjuvant chemotherapy post-op. During follow up 59% of patients suffered disease recurrence with a median DFS of 20.1 months (CI: 11.5–33.5). The administration of palliative chemotherapy upon recurrence was associated with an improvement in survival of 11 vs 5.3 months (HR 3.5 p 0.01).

Conclusions

Surgery for pCCA remains a significant undertaking for both patient and clinician with high rates of morbidity and mortality. Long term survival is achievable but recurrence rates remain a challenge. Overall our mortality, morbidity and survival rates are comparable to that reported in other Western centres.
HPB P22 The stepwise implementation of robotic HPB program in a single UK centre; a continuum of practice
Authors: Ogbemudia Ann , Mastoridis Sotiris , Chadha Radhika , Lakunina Lana , Gordon-weeks Alex , Udupa Venkatesha , Reddy Srikanth , Silva Michael , Soonawalla Zahir
Published: December 2022

Background

Since the first documented use of a robot for surgery in 1985, there has been a rapid global adoption of this technology. Hepatobiliary and pancreatic (HPB) surgery centres worldwide are increasingly sharing their robotic experiences, testing its potential to become a new standard for surgery. We are among the small number of known robotic HPB programs in the UK and here describe our stepwise implementation and share our learning curve.

Methods

We performed a retrospective review of our prospective database of robotic HPB surgeries carried out by two surgeons from the start of the program in September 2021 up to May 2022. Metrics analysed included surgery console times and 30-day patient perioperative outcomes. Results are shown as mean +/- std unless stated otherwise.

Results

There were 53 cases performed in 8 months. For all cases mean patient age was 58 years (range 26–82 years), BMI was 27.3 ± 4.3 Kg/m2 and docking time was 3.20 ± 0.97 minutes.

There were 2 defined performance phases; early practice which included the following cases - marsupialisation of liver cysts (n = 7), cholecystectomies (n = 22) and radical cholecystectomies (n = 5). Intermediate practice followed when no decrease in console time was observed, and patients’ safety was maintained, and cases included liver wedge resections (n = 9) and distal pancreatectomies (n = 10).

Mean console time for marsupialisation of liver cysts was 39 ± 0.01 minutes, cholecystectomies 44 ± 0.01 minutes, radical cholecystectomies 109 ± 0.01 minutes, liver wedge resections 87 ± 0.04 minutes and distal pancreatectomies 153 ± 0.03 minutes. Length of stay for distal pancreatectomies was 6.8 ± 2.2 days and liver wedge resections 2.3 ± 1.1 days.

There was 1 conversion to open, 1 reoperation and 3 readmissions. There were 9 postoperative complications Clavien-Dindo grade I (n=1), grade II (n=5), grade IIIa (n= 2) and grade IIIb (n= 1). The rate of pancreatic fistula (International Study Group of Pancreatic Fistula classification grade B) was 3% (n=3), there were no 30-day mortalities.

Conclusions

Our outcomes show acceptable safety metrics during the implementation our HPB robotic program. Only after evaluating our learning curve and patients’ outcomes in each performance phase do we progress to the next phase, which for our program is the complex phase and includes pancreaticoduodenectomy and more complex liver resections.
HPB P24 Comparison of outcomes of Deb-TACE in patients with HCC larger than 5cm compared with HCC less than 5cm
Authors: Youssef Fady , Fouad Mina , Jackson Andrew , Hossain Tan , Aravinthan Aloysious , Sanyal Sudip
Published: December 2022

Background

Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with intermediate-stage hepatocellular carcinoma (HCC). Drug-eluting bead (Deb)-TACE is associated with a reduction in liver toxicity and drug-related adverse effects compared with chemotherapy-TACE. This retrospective paired cohort study compares the outcomes of DEB-TACE in patients with HCC greater than and less than 5 centimeters.

Methods

Sixty-nine patients had Deb-TACE as the primary treatment for HCC over a 3-year period from May 2019 -to May 2022. Patients were paired into two unmatched groups according to tumour size. Group A; tumour size > 5cm and group B tumour size < 5cm. Each group was then compared following a single or repeated treatment of Deb-TACE. Tumour response was evaluated using the standardised modified Response Evaluation Criteria in Solid Tumours (mRECIST) to detect evidence of tumour size regression. Patients were classified as having either a complete response (CR), partial response (PR), stable disease (SD),or progressive disease (PD). Also, any adverse outcomes including hepatic decompensation were recorded

Results

Group A,(34.48%) 10 patients had a single session of Deb-TACE. Post-treatment surveillance showed that 4 patients (44.44%) showed CR, PR in 2 patients (22.22%), SD in 1 patient (11.11%), 2 patients (22.22%) had PD, one patient was still waiting for his follow-up surveillance. On the other hand,(65.52%)19 patients had repeated sessions, CR was evident in 2 patients (10.5%), PR in 1 patient (5.2%), SD in 3 patients (15.7%), PD in 2 patients (10.5%), 7 patients (36.84%) had initial PR followed by CR, 2 patients (10.5%) showed initial SD then PD and finally 2 patients (10.5%) were PR and became PD.

Group B, 18 (45%) patients had single Deb-TACE, Patients showing CR were 7(58.3%), PR was detected in 2 patients (16.67%), one patient (8.33%) had SD, 2 patients (16.67%%) showed PD, and 6 patients were still waiting for their surveillance, no response recorded for them. (55%) 22 patients had repeated Deb-TACE sessions. 3 patients(13.6%) showed CR, PR were 4 patients (18.18%), one patient (4.5%) had SD, PD were 6 patients (27.27%). However, 3 patients (13.6%) were PR then showed CR,3 patients (13.6%) were PR became PD and finally 2 patients (9%) were PD became CR.

Conclusions

DEB-TACE is effective for HCCs > 5cm with a response rate of 66.67% in patients who had a Single DEB-TACE dose as their first treatment and it increased to 79% in patients who had repeated deb-TACE; however, that was not statistically significantly different (P = 0.48). The Patients group who had HCC <5 cm showed responses up to 83% with single-dose compared to 59% for repeated DEB-TACE, this was not statistically significant with (P = 0.25) . There was no difference in complications between the two groups.
HPB P25 Incidence of pancreatitis induced vascular complications in a tertiary care hospital
Authors: Shameem Fathimath Jila , Ghazanfar Mudassar
Published: December 2022

Background

Pancreatitis (AP) is a common cause of hospital admission, which can lead to vascular complications such as splanchnic venous thrombosis (SpVT), pseudoaneurysm and haemorhage. These complications can happen with both acute and chronic pancreatitis and can be associated with high morbidity and mortality.

The aim of this study was to assess incidence of vascular complications in acute pancreatitis patients in a tertiary care hospital. Secondary aims included describing patient demographics, length of hospital stay, critical care admission, mortality, and assess the association between SpVT and pancreatic necrosis and mortality.

Methods

This study was done as part of year five elective project in University of Aberdeen Medical School. A retrospective study of acute pancreatitis patients who stayed in Aberdeen Royal Infirmary (ARI) or Dr. Gray's Hospital for ≥2 weeks and cases of mortality from acute pancreatitis irrespective of hospital stay between January 2018 to December 2019.

Cases were identified from Health intelligence central data as per local governance protocol. Hospital electronic system (TrackCare) was used to review the clinical and radiological details and data was entered in SPSS software version 27 for analysis. Frequencies and percentages were shown for the categorical data and chi square test was used to compare the variables. A p value less than 0.05 was taken as statistically significant.

Results

Total 293 patients were admitted with acute pancreatitis during the study period. 52 patients met the inclusion criteria for our study.

Of the 52 patients, 50 patients had a CT scan. There were 12 patients (24%) with evidence of vascular complications. 22% of patients had SVT and pseudoaneurysm was seen in 2% of cases. There was no case of haemorrhage. The overall mortality from AP during the study period was 6.5%. There was no statistically significant association between SVT and pancreatic necrosis or mortality.

Conclusions

Splanchnic venous thrombosis was a more frequent complication compared to pseudoaneurysm and haemorrhage in AP. There was no association between SVT and necrosis or mortality.
HPB P30 What is the Impact of Neoadjuvant Chemotherapy on Survival after Palliative Procedures for Pancreatic Ductal Adenocarcinoma?
Authors: Halle-Smith James , Roberts Keith
Published: December 2022

Background

Neoadjuvant chemotherapy (NAT) is increasingly offered to patients before attempting resection of pancreatic ductal adenocarcinoma (PDAC), most often to downstage locally advanced tumours but may also potentially control existing micrometastases. Unfortunately, curative resection may still not be possible in these patients. Therefore, the aim of this study was to evaluate the impact of neoadjuvant therapy on outcomes after palliative procedures for unresectable PDAC.

Methods

All patients who underwent a palliative procedure for PDAC between 2014–2020 were identified from our prospectively collected and maintained institutional database. Relationships between demographics, perioperative variables, chemotherapy and postoperative survival were explored.

Results

131 patients were suitable for inclusion, of which 15 patients received neoadjuvant chemotherapy (12%). The most common reason for palliative procedure was local invasion (50%) and the most common palliative procedure was combined gastrojejunostomy and hepaticojejunostomy (55%). The NAT group were significantly younger (63 years vs. 70 years; p=0.012) but other demographic information was similar. There was no significant difference in overall survival between the NAT and no NAT groups (p=0.216). Significant independent predictors of 6-month survival were palliative chemotherapy (PC) (p<0.001) and locally advanced disease being the reason for unresectability (p=0.037), compared to liver or peritoneal metastases. PC was the only independent predictor of 12-month survival (p<0.001).

Conclusions

NAT does not appear to significantly influence survival after palliative procedure for PDAC; PC remains the main factor determining survival. Low patient numbers in the NAT group reduce the statistical power of the present study, so multicentre collaborative studies are required to further investigate this important question.
HPB P31 Early Postoperative Anthropometric and Nutritional Measures Correlate with Fitness for Adjuvant Chemotherapy after Pancreatoduodenectomy
Authors: Halle-Smith James , Carnegy Alasdair , Loo Joan , Roberts Keith
Published: December 2022

Background

Adjuvant chemotherapy (AC) improves survival after pancreatoduodenectomy (PD) for periampullary cancer. Unfortunately, not all PD patients are fit for AC, and it is likely that perioperative malnutrition plays a role. Therefore, the aim of this study was to investigate the relationship between early postoperative anthropometric and nutritional measures with fitness for adjuvant chemotherapy after PD.

Methods

All patients undergoing PD for periampullary cancer between 2018–2020 at our institution were reviewed. Those who were referred for AC were included in the study and split into two groups: those who received AC and those who were not fit enough to receive AC. Demographic, perioperative, anthropometric, nutritional and outcome measures were compared between the two groups.

Results

66 patients were suitable for inclusion in the study, of which 15 (23%) were not fit for AC. Overall survival was significantly greater in the AC group (29.7 months vs. 16.7 months; p=0.037). Body mass index (BMI) was similar between the groups at admission but during inpatient stay dropped significantly more in the no-AC group (-1.34 kg/m2 vs. -0.10 kg/m2; p=0.035). BMI was also significantly lower at first follow-up (3–4 weeks after surgery) in the no-AC group (20.2 kg/m2 vs. 25.2 kg/m2; p=0.018). Albumin was similar between the two groups on admission and discharge. However, at first follow-up albumin was significantly lower in the no-AC group (31 g/L vs. 38 g/L; p=0.019). There was no difference in postoperative complications between the two groups.

Conclusions

BMI and albumin in the early postoperative period appear to be significantly related to fitness for adjuvant chemotherapy. By routinely measuring these values and intervening in those struggling with nutrition postoperatively before their first Oncology appointment, it may be possible to increase the proportion of patients fit enough to receive AC, and thus improve survival after PD. BMI and albumin have some limitations so future work should concentrate on more reliable measures such as body composition measures.
HPB P34 Complexity alone is not an indication for resection of liver cysts
Authors: Al-Khafaji Nadeem , Abdalkoddus Muhammad , Wong Newton , Roach Huw , Skipworth James , van Laarhoven Stijn , Abbadi Reyad
Published: December 2022

Background

Most cystic liver lesions are simple biliary cysts (SBC) and have no malignant potential. Surgical deroofing may be indicated if symptomatic. Mucinous cystic neoplasms (MCN) represent less than 5% of liver cysts but can progress to mucinous cystadenocarcinoma and therefore require formal liver resection. While an MCN would demonstrate complex features on imaging, SBC may have similar appearances following episodes of infection or bleeding. CT, MR and US scans therefore have low positive predictive value for MCN, and most complex cystic liver lesions represent SBC. As a result, the decision to resect a complex cyst can be difficult for both patients and clinicians. We aimed to review our practice.

Methods

Patients treated surgically for cystic liver lesions in a tertiary Hepatobiliary (HPB) centre between 2016 and 2019 were identified. Data on preoperative imaging, patient demographics, histology and follow up were obtained retrospectively.

Results

18 patients were treated surgically for liver cysts. Cysts were solitary in 3/18 cases. Eight were classified as complex on preoperative radiology. Five (all were complex and one was solitary) underwent formal liver resection and the remaining 13 were deroofing procedures. Patients who underwent liver resection were significantly more likely to have an asymptomatic liver cyst (4/5 vs 0/13, chi Squared, p<0.01). None of the resected specimens represented MCN, and complex characteristics on imaging were attributed to episodes of bleeding or infection. 14/18 patients were followed up for a median of 9 months (range: 2–36) without major adverse events.

Conclusions

Surgical risks of liver resection must be balanced against likelihood of future malignancy. Cyst complexity alone is not an indication for resection and selected cases can be fenestrated if there are no other features to strongly suggest MCN, such as being solitary or in the absence of history suggesting cyst haemorrhage or infection
HPB P35 Fluorescence guided resection of Liver Tumours: Same day administration of indocyanine green with SPY- Colour Segmented Fluorescence imaging to identify tumours intra-operatively
Authors: Karmarkar Rahi , Benjafield Anastasia , Aroori Somaiah
Published: December 2022

Background

Indocyanine green (ICG) fluorescence imaging is a real-time navigation tool that has shown promising liver surgery results. Several regimes have been described regarding optimum timing and dose of ICG administration. Visually different fluorescent enhancement patterns correlate with different pathologies to aid the identification of lesions intra-operatively. This study aims to present our experience with using the Colour Segmented Fluorescence (CSF) model and same-day administration of low dose ICG in the resection of liver tumours.

Methods

We present a single surgeon (SA) experience using indocyanine green fluorescence image-guided surgery (I-FIGS) at University Hospitals Plymouth, UK. I-FIGS was used between November 2020 and March 2022 in 15 patients with suspected liver tumours. ICG was administered intravenously at a dose of 0.02 to 0.03 mg/kg IV 2–3 hours prior to liver surgery. Using the SPY CSF mode, the image is scaled to NIRF fluorescence intensity to identify the liver tumours and their margins intra-operatively.

Results

A total of fifteen patients (eight males) with a median age of 71 years (36–86) underwent I-FIGS during the study period. Of these, 67% underwent laparoscopic liver surgery, 78% underwent non-anatomical resections, and 33% underwent re-do liver surgery. The average size of the tumour was 40.6 mm, and median number of tumours was one. All lesions were visible in CSF mode, and all had a signet ring appearance. The histology of the tumours confirmed a well to moderately differentiated colorectal metastasis in 13 (86%) patients and hepatoma in two patients. R0 resection was achieved in 11 (76%) of patients. In two patients with R1 resection, the tumour was right on the right hepatic vein, and R0 would not have been possible. The resection margins were clear in two other patients but <1mm. The overall false positive rate in our experience with I-FIGS was 3%.

Conclusions

In our limited experience, low-dose ICG administered at least 2–3 hours prior to surgery can accurately identify liver tumours and their margins in CSF mode. Superficially located lesions are easily identifiable under CSF mode, and CSF mode helped us identify the lesions and mark the resection margin. The use of ICG is an important advancement in liver surgery, and further research is needed to optimise image interpretation and correlate with clinical resection outcomes.
HPB P38 Bile duct injuries during cholecystectomy – Experience of referrals to a tertiary centre over a 7 year period
Authors: Thillai Manoj , Reetoo Salil , White Molly , Nicoll Kenneth , Thomasset Sarah
Published: December 2022

Background

Laparoscopic Cholecystectomy is a common procedure performed both in elective & emergency setting for gall stone disease. Current literature states that the incidence of bile duct injuries is between 0.5–1.5%. These are iatrogenic catastrophe associated with significant perioperative morbidity, mortality, reduced long-term survival and reduced quality of life. Early identification and referral is key in help managing these injuries. In delayed cases, the choice and timing of the appropriate reconstructive procedure have a critical role in long-term prognosis.

Methods

A retrospective analysis of all patients referred to the Royal Infirmary of Edinburgh between 2014 and 2021 was undertaken. All patients referred with suspected bile duct injuries were included in the study. Strasberg – type A (cystic duct leak), bile leaks following subtotal cholecystectomy and trauma were excluded. All injuries were classified according to the Strasberg classification.

Results

A total of 34 patients were identified during the study period. Five patients (15%) had previously had abdominal surgery. Six patients (18%) had CBD stones at the time of cholecystectomy. Twenty one patients (62%) who sustained a bile duct injury were undergoing elective surgery. Bile duct injury was identified intraoperatively in 21 (62%) of cases. Eighteen patients (52%) were referred immediately, within 24 hours of the injury. Eight patients were referred early (within 72 hours) and eight patients were referred late (>10 days since injury). An E2 injury was most commonly seen, with 11 patients having this type of injury, followed by an E1 injury which was seen in 7 patients. An arterial injury was seen in 4 patients. A hepaticojejunostomy was the most commonly performed surgical procedure (22 out of 27 patients treated surgically). Immediate repair (within 72hours) was performed in 18 patients and this group of patients had the shortest hospital stay (10 days) and lowest long-term complication rate (5%).

Conclusions

The majority of bile duct injuries that were referred happened during elective cholecystectomies. Significant delays in the identification of bile duct injuries and referral to tertiary centres persist. These delays continue to have a significant impact on hospital stay and long-term complications rates.
HPB P39 Do indeterminate pulmonary nodules in patients undergoing resection for pancreas cancer influence pulmonary metastasis and survival outcomes?
Authors: Oyende Olamide , Anis Fady , Cameron Iain , Gomez Dhanny , Sanyal Sudip
Published: December 2022

Background

The significance of indeterminate pulmonary nodules (IPNs) on preoperative imaging in the surgical resection of pancreatic cancers remains a clinical dilemma. IPNs are defined as ≥ 1 well-defined, non-calcified lung nodules that are ≤ 1cm in diameter. We report the prevalence and impact of IPNs in surgically managed pancreatic cancer patients from our centre.

Methods

We studied patients who had attempted/successful surgical resection of pancreatic cancers between 2014 and 2020. The summary statistics are presented as frequencies and percentages, while Fisher's exact test was used to calculate p value for the compared variables including the presence of IPNs, pulmonary metastasis and death. P value of <0.05 was considered statistically significant.

Results

Our study included 262 patients – 204 (77.9%) had surgical resections including pancreaticoduodenectomy (with or without portal venous resection) or total or distal pancreatectomy, while 58 (22.1%) had trial dissection, bypass and/or laparoscopy. All patients had a preoperative chest computed tomography (CT) scan. 25/262 (9.5%) had IPN on preoperative CT scans.

15/25 (60%) had solitary IPN, 2/25 (8%) had two IPNs, 3/25 (12%) had three IPNs, 1/25 (4%) had 6 IPNs and 4/25 (16%) reported multiple/plural IPNs. In patients with more than 1 IPN, only one patient had unilateral pulmonary nodules.

23/262 (8.8%) developed pulmonary metastasis. Of these, none had IPN preoperatively. There was no statistically significant association between IPN and pulmonary metastasis (p = 0.1428).

Neoadjuvant chemotherapy was given to 13/262 patients. None of these patients had IPN pre-operatively, but 4 of them had recurrent/metastatic disease (3 Liver & 2 Pulmonary). IPN was found in 3 patients on post-operative imaging, all three developed metastatic disease after pancreaticoduodenectomies. As at 31st of October 2021, 177/262 patients had died. There was a statistically significant association between pulmonary metastasis and mortality (p = 0.0379). On the other hand, an association between IPN and mortality showed no statistical significance (p = 1.0).

Conclusions

Our study suggests that IPN is not linked to pulmonary metastasis in pancreatic cancer patients that were offered surgical resection. The presence of IPN did not impact mortality. Therefore, we conclude that IPN should not be used as a determining factor for surgical management of pancreatic cancers.
HPB P41 Pitfalls in establishing a preoperative diagnosis; correlating the radiological and histopathological findings of suspected intraductal papillary neoplasm of the bile duct (IPNB)
Authors: Hughes Daniel , Turaga Sanchit , Gordon-Weeks Alex , Fryer Eve , McWeeney Doireann , Bungay Helen , Silva Michael
Published: December 2022

Background

Intraductal papillary neoplasm of the bile duct (IPNB) represents a cohort of uncommon biliary tract tumours. It is commonly unrecognised or misdiagnosed in cross sectional imaging of the liver. This rare tumour is of significant clinical importance as it serves as a pre-cursor lesion for Cholangiocarcinoma. The diagnostic work up of a patient with a suspected IPNB remains predominantly based on imaging and as of yet no consensus has been achieved regarding the optimal diagnostic algorithm. The aim of this study was to compare the radiological and clinico-pathological features of patients with confirmed or suspected IPNB managed in a single tertiary center.

Methods

Retrospective review of a departmental database of consecutive patients with suspected IPNB was performed. Clinical information regarding patient demographics, disease presentation, radiological imaging characteristics and histo-pathological features was analysed.

Results

Eighteen patients with suspected IPNB were noted, of which histological confirmation was present in eight cases (62%). The most frequent presentation of IPNB was of an incidental finding (50%). The diagnosis of IPNB was made following MRI in 63% of cases. Invasive adenocarcinoma was present in five patients (63%). In the remaining three patients, low grade dysplasia was noted within their IPNB tumours.

Conclusions

IPNB is frequently associated with concurrent invasive malignancy. Observation alone is insufficient. Radiological assessment of these tumours remains as the fundamental investigation for diagnosis. However, without confirmatory histology perioperatively, the diagnosis cannot be assured therefore the decision for management must be based upon a patient-centered discussion and a careful evaluation of risk.
HPB P48 Minimally invasive HPB surgery in the UK from consultant and trainee perspectives
Authors: Kourdouli Amar , Dennison Ashley , Garcea Giuseppe
Published: December 2022

Background

This survey took a ‘'snapshot’’ of prevailing attitudes towards minimally invasive HPB surgery from a consultant and trainee perspective.

Methods

Between November 2020 and January 2021, two google surveys were emailed to all HPB tertiary centres in the UK. The questionnaire contained 33 and 31 questions respectively regarding minimally invasive practice and training.

Results

Thirty-five HPB consultants completed the survey. The most common indications for conversion were failure to progress (91.4%), excessive blood loss (85.7%), access issues (85.7%). The majority (78.8%) of HPB surgeons undertook minimally invasive distal pancreatectomy (MIDP). One consultant undertook minimally invasive pancreaticoduodenectomy (MIPD), 48.4% declared not performing MIPDs due to uncertainty of its superiority. Eighty-five-point seven percent performed minimally invasive minor liver resection and segementectomy (MImLRS), 70.6% reported better outcomes with this approach; 28.6% of consultants performed minimally invasive major liver resection (MIMLR), 23.3% reported better outcomes with MIMLR. Half of HPB trainees did not have access to complex laparoscopic HPB procedures; 72.2% desired fellowship training.

Conclusions

MImLRS and MIDP are accepted approaches by most HPB consultants correlating with a perception that outcomes are better/comparable to open approaches, in contrast to MIPD and MIMLR. HPB trainees lack laparoscopic HPB exposure leading them to seek further experience with fellowships.
HPB P59 Is the lymph node ratio a relevant prognostic score neo-adjuvant chemotherapy for pancreatic cancer?
Authors: Pande Rupaly , Hodson James , Chatzizacharias Nikolaos , Sutcliffe Robert , Bartlett David , Marudanayagam Ravi , Mirza Darius , Isaac John , Roberts Keith
Published: December 2022

Background

Lymph node ratio (LNR) is a strong prognostic marker in pancreatic cancer (PDAC). In recent years, use of neoadjuvant chemotherapy (NAT) has increased, where it is associated with a higher rate of N0 resections, compared with a surgery first approach. The prognostic accuracy of the LNR after NAT has not been assessed.

Methods

Retrospective review of prospectively collected data from 2008–2020 of all patients undergoing pancreaticoduodenectomy (PD) for PDAC. Basic demographics, pathological and clinical outcomes were analysed using standard statistical tests. Cox regression and Kaplan-Meier analyses were performed.

Results

Retrospective review of prospectively collected data from 2008–2020 of all patients undergoing pancreaticoduodenectomy (PD) for PDAC. Basic demographics, pathological and clinical outcomes were analysed using standard statistical tests. Cox regression and Kaplan-Meier analyses were performed.

Conclusions

NAT reduces the predictive accuracy of the LNR in resected pancreatic cancer; alternative prognostic models will require development.
HPB P66 Resection margin status, five-year recurrence and five-year survival in ampullary adenocarcinoma and cholangiocarcinoma patients who undergo pancreatoduodenectomy
Authors: Russell Thomas , Labib Peter , Aroori Somaiah
Published: December 2022

Background

Patients with a suspected early cancer affecting the periampullary region may be offered resection in the form of pancreatoduodenectomy (PD) if they are a suitable candidate. Whilst this offers some patients a potential cure, the operation is high-risk and disease recurrence is common. Patients who are found to have ampullary adenocarcinoma (AA) or cholangiocarcinoma (CC) on their postoperative histology are known to have relatively favourable oncological outcomes if their resection margins are clear. This study aimed to investigate the correlation between a positive margin and both five-year recurrence and five-year survival.

Methods

Data was extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective cohort study of outcomes following pancreatoduodenectomy performed for pancreatic head malignancy (29 centres in 8 countries, n=1,484). Patients with postoperative histology suggestive of AA and CC were identified and compared to one another by their resection margin status. Five-year recurrence and survival rates were compared using Fisher's exact test.

Results

A total of 394 patients had AA (26.5%) and 364 of these (92.4%) had their resection margin status recorded. Of these, 295 (81.0%) had no positive margins (R0), 69 (19.0%) had at least one positive margin (R1) and zero (0.0%%) had an incomplete resection (R2). Patients with R0 disease had lower five-year recurrence (41.4% vs 63.8%, p=0.0012) and higher five-year survival rates (59.0% vs 30.4%, p<0.00001) compared to those with R1 disease. A total of 205 patients had CC (13.8%) and 202 of these (98.5%) had their resection margin status recorded. Of these, 113 (55.9%) had no positive margins (R0), 86 (42.6%) had at least one positive margin (R1) and three patients (1.5%) had an incomplete resection (R2). Patients with R0 disease had lower five-year recurrence (60.2% vs 76.7%, p=0.015) and higher five-year survival rates (38.1% vs 15.1%, p=0.0004) compared to those with R1 disease.

Conclusions

In our multicentre study, the majority of patients who underwent PD for AA or CC had no positive resection margins. These patients had significantly improved five-year outcomes.
HPB P67 Patterns of recurrence after pancreatoduodenectomy for pancreatic cancer and the effect of palliative chemotherapy on survival
Authors: Russell Thomas , Labib Peter , Aroori Somaiah
Published: December 2022

Background

Pancreatoduodenectomy (PD) is recommended in fit patients with suspected early pancreatic ductal adenocarcinoma (PDAC) affecting the pancreatic head. Unfortunately, recurrence rates are high and only a minority achieve long-term survival. This study aimed to study the patterns of recurrence in patients who undergo PD for PDAC and investigate the impact of palliative chemotherapy on survival.

Methods

Data was extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective cohort study of outcomes following PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1,484). Patients with PDAC who developed recurrence within five years of their operation were identified. The site of recurrence and details of palliative chemotherapy (if any) was recorded for each patient. Overall survival (OS) and time from recurrence to time of death was compared between those that received palliative chemotherapy and those that did not using the Mann-Whitney U test.

Results

In total, 885 patients (59.4%) had PDAC. Excluding the 37 patients who died within 90-days, 583 (68.8%) developed recurrent disease within five years (on imaging). The median number of months from time of surgery to time of recurrence was ten months (range: 0–58). Of those with recurrence, 30.4% had local recurrence only, 28.4% had local and distal recurrence, and 41.7% had distant recurrence only. The most common sites of recurrence were the liver (40.7%), the superior mesenteric artery area (33.3%), locoregional lymph nodes (20.2%), the omentum/peritoneum (14.9%), the pancreatic anastomosis site (11.8%), the superior mesenteric vein/portal vein area (10.8%), and the coeliac trunk area (9.4%). Among those with recurrence, 46.1% received palliative chemotherapy. The median number of cycles was four (range: 1–12). Just 41.2% of patients completed their planned course; 28.0% stopped their treatment due to disease progression and 17.4% stopped their treatment due to toxicity. Patients who received palliative chemotherapy had similar median OS to those who did not (both 18 months, p=0.6), however, time from recurrence to time of death was significantly longer in the former (9 vs 3 months, p<0.0001).

Conclusions

In our multicentre study, over two thirds of PD patients with PDAC developed disease recurrence within five-years of their operation. Just under half of these received palliative chemotherapy. Time from recurrence to time of death was significantly longer in those who did receive palliative chemotherapy.
HPB P68 Multimetric MRI detects improved quality of the future liver remnant post-dual vein embolization – a novel finding
Authors: Sundaravadanan Senthil , Welsh Fenella , Sethi Pulkit , Cresswell Ben , Connell John , Knapp Sina , Nunez Luis , Kelly Matt , Brady Michael , Banerjee Rajarshi , Rees Myrddin
Published: December 2022

Background

Optimisation of the future liver remnant (FLR) is crucial to the safety of extended liver resections. This study aimed to assess volume and quality of the FLR pre- and post-dual vein embolisation (DVE) by MRI, in patients with insufficient FLR, needing major hepatectomy.

Methods

Of 81 patients recruited in a clinical trial (Precision1:NCT04597710), seven consecutive patients with colorectal liver metastases underwent multiparametric MRI (Hepatica®) pre- and post-DVE (right hepatic and portal vein). One patient had DVE after a first-stage hepatectomy. FLR volume, fibro-inflammation map (corrected T1) and fat (proton density fat fraction, PDFF) was determined.

Results

All 7 patients underwent uncomplicated DVE, with significant increase in median(range) %FLR volume at liver surgery [45.7(27.0–57.8)% versus 32.4 (19.5–37.7)%, p=0.016], 46 days (range 28–77) post-DVE. Median(range) FLR cT1 scores reduced post-DVE [747.33 (684–884)ms, versus 771.25(726–945)ms, p=0.047; healthy range<794ms], as did median(range) PDFF scores [3.4 (2–13.25)% versus 6 (1.5–22.5)%, p=0.078; healthy range <5.6%]. No patient developed post-hepatectomy liver failure (PHLF).

Conclusions

This novel, non-invasive and readily accessible MRI technique shows that volume and quality of the FLR improves after DVE. This is a significant step in improving surgical decision making in patients with borderline FLR, preventing PHLF and improving outcomes.
OGC P03 Staging of Barrett's neoplasia using artificial neural networks, proof of concept study
Authors: Abdelrahim Mohamed , Siggens Katie , Saiko Masahiro , Maeda Naoto , Htet Hein , Subramaniam Sharmila , Longcroft-Wheaton Gaius , Bhandari Pradeep
Published: December 2022

Background

Endoscopic differentiation between intramucosal and submucosal Barrett's neoplasia has several important implications but remains challenging even for expert endoscopists. Recent studies demonstrated promising results on AI-assisted detection of Barrett's neoplasia, but data on AI-assisted staging is limited. We aimed to develop and validate an AI system for classification of Barrett's neoplasia into intramucosal or submucosal, and compare its performance to expert endoscopists.

Methods

The model, based on VGG-16 architecture, was trained on 117 images of prospectively collected and annotated Barrett's neoplastic lesions. Rotation and random flip were used for data augmentation. The ground truth was the histological staging of endoscopically resected specimens performed by two pathologists with expertise in Barrett's neoplasia. Images comprised of WLI, enhanced imaging, and magnification views. The model was designed to classify images as either intramucosal (pT1a) or submucosal (pT1b). Performance of the AI system was compared to a group of three experts.

Results

The AI model was tested on an independent dataset of 90 images. The accuracy, sensitivity and specificity and AUC of the AI model in differentiating between intramucosal and submucosal neoplasia was 70.9%, 72.5%, 65.7%, and 0.781 respectively. Mean accuracy, sensitivity and specificity of experts were 73.3%, 63.3% and 83.3% respectively. Processing speed of the AI system was 5 ms/image.

Conclusions

This study demonstrates the feasibility of AI-assisted staging of Barrett's neoplasia on endoscopic images. The AI model's performance was comparable to that of experts. More work is needed to further develop this early model and validate its use on real-time video sequences.
OGC P16 What is the prevalence of weight loss in patients undergoing oesophago-gastric surgery and the effect of dietetic intervention pre-op
Authors: Mair Reena , Farah Hafsa
Published: December 2022

Background

Patients with oesophago-gastric (OG) cancer are one of the highest risk groups for malnutrition. Nutrition plays a vital role in supporting this patient group. NICE guidelines (2018) recommend adults with OG cancer have tailored specialist dietetic support before, during and after radical treatment. Unfortunately the research available suggests there are low rates of preoperative dietetic input in this population, which are associated with poorer outcomes.

Methods

Data was obtained via informatics looking at patients who had an oesophagectomy or total gastrectomy between the years of March 2018 –2020 and were followed up at the Queen Elizabeth Hospital Birmingham. A sample of 66 patients was taken. Data was collected on the surgery type, weight changes and whether there was any dietetic input before and / or after surgery.

Results

79% (52) patients had an oesophagectomy and 21% (14) had a total gastrectomy.

Weight loss across all patients post-surgery was apparent post op at 3, 6 and 12 months. Clinically significant weight loss (>10%) was demonstrated at 3 months (27%), 6 months (17%) and 12 months (26%). Unfortunately data was not available for 20% (6 months) and 36% at (12 months).

Only 16 (24%) patients were known to a dietitian pre-op. Out of these 8 (50%) had a feeding tube inserted pre-operatively, 7 of the patients used the tube for enteral feeding. 5 (31%) were seen for oral nutrition support and 3 (19%) for food first approach.

100% of patient had a feeding tube inserted following surgery.

100% of patients had been seen by a dietitian post op both as an inpatient and outpatient.

The percentage of patients seen by a dietitian prior to surgery that had clinically significant weight loss post-op was less than those that were not seen by a dietitian pre op (ie 19% vs 24% at 6 months respectively).

Conclusions

Patients that undergo OG surgery experience clinically significant weight loss postoperatively. The data collected highlights that dietetic input pre-op can lead to less weight loss following surgery. Additional dietetic funding and the set up of a pre-treatment clinic would enable more patients to be seen prior to surgery. Further research needs to be done with a larger sample size over a longer time-frame to provide more representative results on the effects of dietetic input both pre and post surgery.
OGC P17 Surgical and Pathological Outcomes in Patients with a CDH-1 Mutation undergoing Total Gastrectomy: A Systematic Review
Authors: Khiabany Atousa , Kamarajah Sivesh , Liew MeiSien , Griffiths Ewen
Published: December 2022

Background

Patients with CDH1 (E-cadherin) gene mutations have a 60–80% increased lifetime risk of hereditary diffuse gastric cancer (HDGC). Although prophylactic total gastrectomy may reduce long-term risk of gastric cancers, the associated morbidity and mortality remains unclear. This systematic review aims to characterise postoperative surgical outcomes in patients choosing to undergo a prophylactic total gastrectomy.

Methods

A systematic literature search was conducted for studies reporting endoscopic surveillance, surgical outcomes and quality of life (QoL) for patients with a CDH1 mutation undergoing a total gastrectomy.

Results

A total of 991 patients were looked at across 33 studies, with 96% harbouring a CDH1 mutation (n=948). Seven hundred and seventy six patients had endoscopy results reported across 27 studies, with 72% presenting without evidence of cancer foci (n=555). Of these patients, 60% proceeded to have a total gastrectomy (n=333) and histological analysis revealed cancer foci in 83% of the gastrectomy specimens (n=276). Six hundred and forty nine patients were reported to have a total gastrectomy across 33 studies. Pathology outcomes were reported for 528 patients across 26 studies, of which 87% had pT1aN0M0 disease (n=458). Surgical complications were reported for 406 patients across 20 studies. Only 3 studies reported 0 complications. A total of 188 complications were reported across 17 studies, with the most common presentations being anastomotic strictures (23%), pulmonary complications (13%), wound infections (12%) and anastomotic leaks (11%). A total of 5 mortalities were reported in 23 studies over the follow-up period.

Conclusions

Prophylactic total gastrectomy is recommended for patients with a CDH1 mutation. Currently, reliable endoscopic surveillance is lacking and total gastrectomy remains the definitive method for preventing advanced diffuse gastric cancer. Patients choosing to undergo surgery should be provided with adequate counselling, with careful consideration of the associated morbidity.
OGC P30 Impact of COVID-19 Pandemic on endoscopy services in oesophageal and gastric cancers
Authors: Shenoy Sachin , McColl Gillian , Pickard Colette , Robertson Kevin
Published: December 2022

Background

Introduction: The impact of Covid-19 pandemic on the health services across the world is well documented.

Aim

We wished to determine the impact of the pandemic on the provision of endoscopy services and its effect on oesophageal and gastric cancers in our health board.

Methods

A retrospective analysis of data collected from the major cancer network pathway (MCN) database for patients diagnosed with Oesophageal and Gastric cancers for the NHS Ayrshire and Arran Health board in Scotland was performed. Data was collected for the year 2019 (pre-pandemic) and the year 2020 (pandemic) between 1st of January and 31st December for the respective years.

Number of UGI endoscopy procedures performed, mode of presentation, stage at presentation and treatment intent were primary outcome measures. Data was analysed using stata17 software

Results

Data was recorded in 99 and 91 patients with OG cancers for the year 2019 and 2020 respectively. A total of 4176 and 1763 procedures were carried out during the 2 periods respectively. An increase in emergency presentations from 22 to 46% (p<0.05) was noted during this period. Dysphagia and haemetemesis were the most the common indications for the procedure. A decrease in number of routine/urgent and cancer suspect referrals from 78 to 45% was noted during the period. Only nine percent of the patients were offered radical treatment during the pandemic (from 23 percent). Palliative intent and best supportive care were recorded in 55 and 34% of the patients respectively.

Conclusions

The COVID-19 pandemic has had a significant impact on the endoscopy services and management of oesophageal and gastric cancers with an increase in non-Covid harm due to the pandemic.
OGC P33 Prognostic significance of tumour burden and operative technique for metachronous pulmonary metastasis from oesophageal cancer: a systematic review and meta-analysis
Authors: Prasad Pooja , Nevins Edward J , Brown Joshua , Phillips Alexander W
Published: December 2022

Background

Disease recurrence following treatment for oesophageal cancer (OC) remains common despite incremental gains from neoadjuvant chemotherapy. The lung is a common site of distant metastasis following definitive OC treatment. Tumour burden influences the surgical approach utilised in the treatment of pulmonary metastasis from OC. In turn, this impacts patient prognosis. This systematic review sought to identify the impact of tumour burden and surgical approach on 5-year survival following metastectomy of metachronous pulmonary metastasis from OC.

Methods

A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to March 2022. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on the number of metastatic pulmonary tumours and operative techniques utilised were included. A random effects meta-analysis model was used to compare the impact of number of metastatic pulmonary deposits (single vs multiple), and operative approach (wedge vs anatomical resection) on the 5 year survival of patients following metastectomy for metachronous pulmonary metastasis from OC.

Results

Seven non-randomised studies comprising 142 patients undergoing pulmonary metastectomy for metastatic oesophageal cancer were included. The number of metastatic deposits (single vs multiple) did not affect 5-year survival (Risk Ratio = 1.08; 95% confidence interval 0.58–2.02; p = 0.81). With respect to surgical technique, anatomical resection did not confer a survival benefit compared to wedge resection of pulmonary metastases from OC (Risk Ratio = 1.33; 95% Confidence Interval: 0.81–2.19; p = 0.26).

Conclusions

Tumour burden and surgical technique utilised does not impact upon the prognosis of patients undergoing pulmonary metastectomy for metastatic oesophageal cancer. However, current evidence from smaller non-randomised studies remains weak owing to variation in the clinicopathological features of the primary OC and pulmonary metastasis, limiting outcome assessment.