bluuebunny/crossref_metadata_2025 huggingface dataset:
OGC SO38 - Laparoscopic repair of para-conduit hernia post minimally invasive esophagectomy using anterior hiatal suture repair and mobilisation of left liver lobe as reinforcement
Authors: Habib Helai , Newbold Ryan , Knight William , Gossage James
Published: November 2024

Background

Para-conduit hernia (PCH) formation is a rare and late complication of oesophagectomy that is associated with high risk morbidity. Minimally invasive oesophagectomy is associated with increased incidence of PCHs when compared to open or trans-hiatal oesophagectomies. Various techniques to repair PCHs including mesh repair, anterior/posterior hiatal suture repairs or even careful 360 degree repairs have been described in the literature1,2. But the risk of recurrence of PCH still remains high. We describe a unique laparoscopic technique which we believe to be associated with reduced risk of recurrence of PCH post-surgical repair.

Method

We present 4 cases of symptomatic PCH repairs performed laparoscopically. In this unique technique the contents of the sac is reduced and the hiatus is repaired anteriorly with interrupted ethibond sutures. The left lobe of the liver is mobilised and glued to the greater curve omentum along the conduit and the hiatus. This latter step is an additional way of preventing intraabdominal contents from entering the mediastinum.

Data was collected retrospectively to include: patient demographics, details of original MIO surgery, pre-op imaging and details of the presenting symptoms with PCH including imaging, operative details and all available follow up.

Results

Between January 2022 and July 2024, 4 patients underwent laparoscopic repair of paraconduit hernia within 1-2 years post MIO. 3 were male and 1 female aged between 56-71 years. 3 of the procedures were performed electively and one as an emergency. All presented with symptomatic paraconduit hernias and managed with surgery using the technique described above. We present a video of laparoscopic repair as described.

Conclusion

We report a case series of 4 patients presenting with symptomatic PCH that were managed safely with a unique laparoscopic technique using suture repair and left liver lobe mobilisation to prevent recurrence of PCH.

References

1. Watkins et. al. Repair of para-conduit hernia. Thoracic.| Vol 26, Issue 2, P324-340, June 2021. A.A.

2. H.Hietaniemi et. al. Paraconduit hernia after minimally invasive esophagectomy – incidence and risk factors. Scandinavian Journal of Gastroenterology, Vol. 58, No. 7, 764–770

3. J. Sutherland et. al. Postoperative incidence of incarcerated hiatal hernia and its prevention after robotic transhiatal esophagectomy. Surg Endosc. 2011 May;25(5):1526-30.
OGC SO46 - Gastric Cancer: A Comprehensive Literature Review
Authors: Manasseh Mina , Mithany Reda
Published: November 2024

Background

Gastric cancer stands as a significant global health concern with high mortality rates urging urgent attention. This article comprehensively explores the epidemiology, anatomy, risk factors, pathophysiology, clinical presentation, diagnosis, staging, treatment modalities, prevention strategies, and survival rates associated with gastric cancer. Notably, Helicobacter pylori infection, dietary choices, and intricate stomach anatomy play pivotal roles in disease development. Early detection, utilizing staging, grading, and genetic testing for personalized treatment approaches is emphasized. Treatment modalities encompass surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy. Prevention strategies involve lifestyle changes, and genetic counseling. Survival rates vary by stage, highlighting the need for individualized care.

Method

This comprehensive review was conducted by systematically analyzing a wide range of published literature on gastric cancer. The search strategy involved utilizing electronic databases such as PubMed, Google Scholar, and Scopus, with specific keywords including "gastric cancer," "stomach cancer," "epidemiology," "anatomy," "risk factors," "pathophysiology," "diagnosis," "treatment modalities," "prevention," and "survival rates."

Results

Risk Factors: Factors such as Helicobacter pylori infection, dietary choices, tobacco use, and genetic predispositions contribute to gastric cancer risk. Pathophysiology: Genetic alterations, chronic inflammation, and dysregulated signaling pathways drive the development of gastric cancer. Clinical Presentation: Symptoms vary & diagnosis involves a combination of methods, including endoscopy and molecular profiling. Treatment Modalities: Treatment options include surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy. Prevention Strategies: Prevention efforts focus on minimizing risk factors through lifestyle changes, screening, and genetic counseling. Survival Rates: Survival rates vary significantly by stage, ranging from 90-95% for stage 0 to less than 5% for stage IV

Conclusion

The intricate anatomy of the stomach plays a crucial role in disease localization, staging, and treatment planning, with genetic mutations and inflammation central to the pathophysiology. Early detection is underscored through clinical presentation and diagnosis processes, utilizing staging, grading, and genetic testing for personalized treatment approaches, including surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy. Prevention strategies emphasize lifestyle changes and screening, while survival rates vary by stage, underscoring the need for individualized care. In conclusion, addressing gastric cancer requires a collaborative effort to reduce its impact and enhance outcomes on a global scale.
BN SO06 - Comparison of local infiltration of tramadol versus bupivacaine for Post-operative pain relief
Authors: Dawach Adil , Talib Vikash , Kundnani Rakesh , Dawani Surrendar , Rasul Shahid
Published: November 2024

Background

To compare the mean pain score of local infiltration of tramadol and bupivacaine among patients undergoing hernioplasty, a Tertiary Care Hospital, Karachi.

Method

Quantitative and qualitative data was collected, presented and analyzed. Effect modifiers were controlled through stratification to see the effect of these on the outcome variable. Post stratification independent t test was applied taking p-value of ≤0.05 as significant.

Results

Mean postoperative pain at 24 hours in tramadol versus bupivacaine group was 1.65±0.58 and 1.72±0.82 respectively. P-value was 0.001.

Conclusion

Locally infiltrated tramadol prior to herniorrhaphy wound closure provides better pain relief compared to bupivacaine in adult patients
BN SO10 - Virtual Reality in Acute Pain Management of Adult Surgical Patients: Literature Review
Authors: Yershov Danylo , Esfahani Mona Seyed , Khajehpour Salman Heydari
Published: November 2024

Background

Pain is an unavoidable side effect of medical procedures. British Pain Society (BPS) reports almost 10 million people in UK suffer from pain everyday. BPS reported an estimated €5 million per year is spent on managing back pain alone. Pharmaceutical pain management is costly and can cause side effects. Virtual Reality (VR) is a novel technology used to alleviate pain. We performed a literature review to assess the current advances in the pain management using VR.

Method

A literature search was done on the use of VR for pain management across 4 databases (Pubmed, Medline, Embase and Cinahl) using key words virtual reality, acute pain, adult, surgery. 144 non-duplicated studies were found. 66 studies were excluded: 41 were non-acute pain related, 16 involved chronic pain, 9 involved paediatric population. 78 studies with the total number of 1514 patients (n=1514) were included. All studies used VR to relieve acute pain symptoms experienced while undergoing a procedure. The data included sample size, gender, age, specialty, VR type, pain scale, pain score before and after, interventions, key findings and limitation.

Results

VR was tested to control pain in general surgery, plastics, obstetrics and gynaecology, cardiothoracics, orthopaedics, urology, and dentistry. In benign UGI surgery, including fundoplication, paraesophageal hernia repair, esophageal myotomy, and pyloroplasty requiring an overnight stay, the use of VR reduced pain, anxiety and nausea. Overall, no adverse outcomes were reported. No difference in nausea and dizziness between VR and control groups was observed. Active software has been shown to be superior to the passive one. Complete immersion with visual and audio stimulation replaced by VR environment is important. The results were similar in different age groups.

Conclusion

There is a good body of evidence to support the use of VR in pain management in clinical practice. It acts as a good distraction tool. The use of VR was demonstrated to be beneficial in reducing postoperative pain in benign UGI surgery. However, the main areas of application would be in short procedures where it not only delivers better pain management but also increases patient satisfaction and decreases the need for pharmaceutical analgesia, thus bringing down the overall cost.
BN SO17 - When cholecystectomies go wrong: A single-centre review of post-operative complications over a two year period
Authors: Marks Bertram , Sow Karmen , Owen Lucy , Haddington-Ahmed Aysha , Carr William
Published: November 2024

Background

Laparoscopic cholecystectomy (LC) is the main treatment for symptomatic gallstone disease with around 70,000 performed in the UK each year. The majority of these are day case procedures and patients recover well, however, there will always be a risk of more serious complication which can have serious negative effects on patients. The Clavien-Dindo classification of surgical complications is the most recognised method of grading post-operative complications by severity. The aim of our study was to identify our rates and severity of post-operative complication and their management.

Method

All patients who had LC between 1st July 2020 and 30th June 2022 were identified. Patient and operative details were retrieved from their electronic record. A complication was defined as any deviation from the standard post-operative course and was graded according to the Clavien-Dindo classification. 30-day readmission data was collected via hospital episode statistics and outcomes were reviewed on the patient record.

Results

974 patients underwent LC. 30-day morbidity = 8.9%, 30-day readmission = 4.8% and 30-day mortality = 0.31%. Clavien-Dindo grade of complication: Grade 1= 44.7%, Grade 2 = 22.4%, Grade 3A = 12.9%, Grade 3B = 11.8%, Grade 4A = 1.2%, Grade 4B = 1.2%; and Grade 5 = 3.5%. 11 patients (1.1%) returned to theatre; bile leak was the most common indication (73%). Two intra-operative bile duct injuries were observed (0.21%) with one managed locally and the other transferred to the regional HPB centre. 7 patients required post-operative ERCP (0.72%), 57% for CBD stones and 43% for persistent bile leak.

Conclusion

Our study showed that the majority of post-operative morbidity following LC is related to post-operative pain (2.9%) or simple wound infection (1.8%). 2.6% of patients who underwent LC during had a significant complication requiring surgical, endoscopic or radiological intervention or admission to intensive care (Clavien-Dindo > 2). We report a 0.21% risk of bile duct injury and a 0.92% risk of post-operative bile leak. Overall our findings are in keeping with other studies but provide an insight into our local practice and that an area of potential improvement would be better management of post-operative pain.
BN SO19 - Evaluating Wrap Pressure Augmentation Ratio and Physiological Transit Time for Post-Fundoplication Dysphagia
Authors: Miah Ismail , Wong Terry , Gossage James , Zeki Sebastian , Jafari Jafar
Published: November 2024

Background

Post-fundoplication dysphagia affects many patients that can often lead to significant weight loss and reduced quality of life, and prompt some to seek surgical reversal. Current diagnostic methods may not fully explain the dysphagia which may necessitate repeat oesophageal physiology testing. This study retrospectively evaluates two novel markers, Wrap Pressure Augmentation Ratio (WPAR) and Physiological Transit Time (PTT), to better understand and manage the post-fundoplication dysphagia.

Method

The study retrospectively reviewed 54 post-Nissen’s fundoplication patients from January 2020 to May 2024. WPAR was calculated as the ratio of the augmented wrap basal pressure to the median integrated relaxation pressure found during high-resolution manometry following the Chicago Classification guideline [1]. PTT was measured from controlled measurements of antegrade bolus movement [2] during multichannel impedance-pH studies [3]. Patients completed HODQ forms to assess dysphagia [4]. Optimal WPAR and PTT thresholds were determined using Youden’s J index from receiver operating characteristic curves. This study was ethically approved (REC 18/NW/0120, IRAS 333800).

Results

Out of 54 cases (female=28:26, mean age 50.6), 75.9% reported clinical dysphagia post-fundoplication. Significant correlations were found with WPAR (<1.49, p=0.017) and PTT (>0.83 minutes, p=0.028)(see Table 1). These findings suggest WPAR and PTT as effective markers for post-fundoplication dysphagia. The analysis revealed a moderate correlation between WPAR and PTT (r =-0.45, p<0.05), suggesting that lower WPAR values tend to be associated with longer PTT. SensitivityPositive Predictive Valueχ2p-valueWPAR <1.490.610.895.680.017PTT >0.83 minutes0.780.844.820.028

Table 1 showing predictive DR and PTT values for clinical dysphasia post fundoplication.

Conclusion

This pilot study identifies PAR and PTT as promising physiological markers for diagnosing post-fundoplication dysphagia. The moderate correlation between PAR and PTT suggests a potential link, indicating that lower pressure augmentation might be associated with slower oesophageal transit times. These markers could enhance management strategies for affected patients. However, the study's small sample size and lack of a control group limit generalizability. Larger, controlled studies are necessary to validate these findings and further explore the relationship between PAR and PTT.

References

[1] https://onlinelibrary.wiley.com/doi/10.1111/nmo.14058

[2] https://gut.bmj.com/content/70/Suppl_1/A215.1

[3] https://gut.bmj.com/content/68/10/1731

[4] https://www.gastrojournal.org/article/S0016-5085(09)62439-2/fulltext
BN SO23 - From referral to resolution, impact of acute biliary pathway on patients care
Authors: Elmaradny Ahmed , Robinson Steven John , Perry Anthony , Wadley Martin
Published: November 2024

Background

At our trust, we introduced acute biliary pathway to efficiently manage patients presenting with acute biliary pathology. This pathway begins with a referral form containing relevant patient information for triage. A triage team reviews these forms and classifies patients into three categories based on specific criteria.

Method

Patients are triaged into three categories:Red: Patients needing emergency surgery during the same admission.Amber: Patients requiring urgent but non-emergency care, scheduled for an outpatient (OP) appointment for consent, followed by a laparoscopic cholecystectomy within 2-3 weeks or 6-8 weeks, based on the pathology.Green: Patients who do not meet the criteria for red or amber are referred for further outpatient assessment before definitive management.

Results

Over four months , 202 referrals were received. Approximately 50% (102 patients) were referred to the outpatient department. Of the remainder, 45% were categorised as red and had IP cholecystectomy, with a mean length of stay of 1.5 days post-surgery across 30 operations. The remaining patients were managed as amber, resulting in 22 operations. The total complication rate was low, with only 2 cases managed conservatively, and 4 patients required re-admission before definitive treatment. The average wait time for a clinic appointment was 2 weeks, while the average wait time for surgery was 8 weeks, with a total of 6 cancellations.

Conclusion

The acute biliary pathway demonstrates effectiveness through a low complication rate and timely management of patients. This approach improves the efficiency of patient care and reduces the need for emergency re-admissions. More importantly, this model is straightforward enough to be implemented in any high-volume centre with a sufficient level of expertise in treating biliary patients.
BN SO24 - Predicting incidental gallbladder cancer: A protocol for identifying predictive factors of incidentally detected gallbladder cancer and prospective validation of a scoring system to allow selective histological analysis of the gallbladder
Authors: Brown Oliver D , Sorrell Lexy , Latour Jos M , Aroori Somaiah
Published: November 2024

Background

Incidental Gallbladder Cancer (iGBC) is a rare complication of cholecystectomy, with a UK incidence of 0.14-0.3%. Despite its rarity, most gallbladder specimens are analysed histologically. Some comparable countries undertake Selective Histological Analysis (SHA), selecting high-risk specimens for histology based on clinical judgement or postoperative inspection. However, evidence suggests a third of diagnoses can be missed with these approaches. Swedish and Dutch diagnostic scores incorporate few risk factors and are not generalisable to the UK. We present a protocol for a UK study aiming to develop a detailed diagnostic score for iGBC to reliably stratify patients by their risk of iGBC.

Method

This UK multicentre, cross-sectional, trainee-led study includes adult patients undergoing cholecystectomy for benign indications. It incorporates a feasibility study and an adaptive design, and has been submitted for ethical review. A parallel qualitative study will explore attitudes towards the risk of iGBC and the acceptability of SHA among patients and healthcare professionals. The feasibility phase will include 500 patients over six months, collecting data on patient risk factors for iGBC, preoperative investigations, operative findings, and histology results. Exclusion criteria include cholecystectomy as a secondary procedure, polyps over 5mm, and conditions known to increase the risk of biliary tract cancers.

Results

Following the feasibility phase, the recruitment rate and data completeness will be evaluated. Outcomes will be assessed against anticipated values, and collaborators will be surveyed to identify challenges with data collection. Necessary adjustments to the electronic case record form or overall protocol will be made, and the recruitment target will be recalculated based on an updated sample size calculation. When the study meets specified progression criteria, additional sites will be recruited, and data collection will continue to meet the required sample size. A detailed statistical analysis plan will be provided at a later date.

Conclusion

This protocol describes a UK diagnostic modelling study aimed at developing a risk-stratification score for iGBC in patients undergoing routine cholecystectomy, identifying high-risk patients and facilitating SHA.
BN SO30 - One hundred consecutive Laparoscopic Heller's Cardiomyotomy & Fundoplication – a personal series
Authors: Sinha Yashashwi , Howey Caitlin , Jerome Ellen , Fernando Tyrrel , Menon Vinod
Published: November 2024

Background

Oesophageal Achalasia (OA) is an uncommon primary oesophageal motility disorder, characterised by the loss of inhibitory neurons in the oesophageal myenteric plexus. The primary goal of treating OA is to alleviate dysphagia caused by the functional obstruction of the distal oesophagus due to the inability of the lower oesophageal sphincter (LOS) to relax appropriately after swallowing. Heller's cardiomyotomy (HCM) remains a standard treatment for OA.

The aim of this study was to assess the symptomatic improvement and post-operative outcomes following HCM with fundoplication at our centre.

Method

All patients underwent HCM through laparoscopic blunt muscle separation technique, between January 2005 and March 2024, by a single surgeon. Retrospective review of electronic and compiled paper patient records were analysed to assess patient demographics, preoperative symptoms, operative details, length of stay (LOS), complications, post-operative symptoms, gastroscopy and pneumatic dilation (PD) as well as revisional surgery.

Primary outcomes assessed were binary changes in key symptoms of weight loss, dysphagia, retrosternal pain and regurgitation. Comparison of pre and post-operative outcomes were performed using paired t-test. A p-value of <0.05 was considered statistically significant.

Results

100 procedures involving 99 patients (average age 50 years, 43% female), 1 conversion to open and 1 revision at 3 years. ASA grades were 1 (27%), 2 (58%), and 3 (15%).

Median LOS was one day, median follow-up 99 months.

Post-operatively; weight loss persisted in 11% of patients from 48%, dysphagia reduced from 98% to 42%, retrosternal chest pain from 39% to 20% and regurgitation from 57% to 24% (all p<0.05).

2 patients required (PD) ≤30 days (CD≥3). 36 patients underwent PD at median of 13 months, 20 needed repeat PD. None of the patients developed cancer.

Conclusion

As demonstrated in this large series of 100 consecutive patients, HCM remains one of the best treatment modalities for OA. Key symptoms of OA significantly reduced following HCM.

Our technique avoided the use of energy devices, ensured a short hospital stay and durable symptom improvement, lends support to its continued application in managing this condition.
BN SO32 - Operative techniques and outcomes following giant hiatus hernia repair: 5 years of tertiary centre experience
Authors: Sinha Yashashwi , Howey Caitlin , Nandra Saroop , Fernando Tyrrel , Akbari Khalid , Tan Lam Chin , Menon Vinod , McLaughlin Euan
Published: November 2024

Background

Giant hiatus hernia (GHH) repair is a complex surgical challenge, often requiring advanced techniques and specialised expertise. Whilst the repair of small hiatus hernias is well-documented, the optimal strategy for giant hernias remains debated.

This study reviews five years of experience at a tertiary centre, focusing on operative techniques and outcomes. The aim is to identify trends and best practices that enhance patient outcomes and minimise complications in the repair of GHH.

Method

All patients undergoing primary GHH surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service.

Retrospective review of electronic records were utilised to document patient demographics, type of hernia, operative details including surgical approach (open/laparoscopic/robotic), use of fundoplication, use of mesh and gastropexy.

Outcomes measured included 30-day morbidity (Clavien-Dindo (CD) grading), 30-day mortality, binary symptom recurrence, length of stay (LOS), need for return to theatre (RTT) and RTT versus mesh use. Analysis undertaken using paired t-test. Statistical significance was set as p<0.05.

Results

91 patients underwent GHH repair with median age 70 (31-93) years, 66.7% female, average BMI 30.8(±5.4). ASA: ≤2 (72.4%), 3 (25.5%), 4 (2.1%). Hernia types: 2 (15.7%), 3 (55.4%), 4 (28.9%).

Approach: open 6.6%, laparoscopic 61.5%, robotic 31.9%.

Fundoplication in 88%, gastropexy in 13%, 2 cases utilised both.

Mesh: 91.2% without, 8.8% biologic, nil prosthetic.

Median LOS 2 days (0-161). Median follow-up 8 weeks (1-172).

Symptoms recurred in 25.6%. 94.5% had no significant complications (CD≤2). 5.5% had RTT≤30 days. 4.4% RTT>30 days. No mortalities.

No significant difference in RTT and mesh use (p=0.7832).

Conclusion

This five-year review confirms that GHH repair using open, laparoscopic, and robotic techniques is effective and safe, even in an older population with high ASA scores. The study highlights minimal complications (94.5% with CD≤2). Only 4.8% required a RTT within 30 days. RTT was not significantly impacted by the use of mesh however this may represent a type two error given the limited use of mesh and low number of patients that RTT. These findings support the tailored use of advanced surgical techniques, mesh, and gastropexy as effective strategies for managing GHH in a tertiary care setting.
BN SO40 - Increasing incidence of medicolegal claims in the NHS for bile duct injury in spite of 30 years of experience and training
Authors: Ingley Paul , Hajibandeh Shahin , Yap Ye Theng , Athwal Terjinderjit , Cheruvu Chandra
Published: November 2024

Background

Bile duct injury (BDI) in cholecystectomy is the most commonly recognised complication occurring in 0.5-1.4% of cases and is associated with significant morbidity and mortality. Despite the increasing number of cholecystectomies and falling number of bile duct injuries due to both surgical experience and recognition of the issue, there appears to be increasing number of payouts by NHS England. We investigated the trend in claims, their underlying cause, stage in procedure where they occurred in the past 20 years to identify areas where improvements could be made, for better patient outcomes and to reduce the medicolegal burden to the NHS.

Method

Data was obtained following a freedom of information request from NHS Resolution UK for cases of bile duct injury. Data analysis was performed on years 2001-2021 to examine the number of claims, their underlying cause and stage in procedure where they occurred as well as average damages awarded and cost to the NHS.

Results

In 2001 there were 11 claims made (costing £644,000) which rose to 28 in 2021 (costing £7,424,000). 400 claims were successful out if 508. The commonest being intraoperative error (49%) followed by operator error (11%) and delay in treatment (8%). The most expensive type of claim arose from intraoperative complications costing a total of £42,836,000 over the period. Pre-operative delays and inadequate patient consent cost the NHS £7,236,000, whilst delays in recognition of BDI cost £8,000,000 between 2001 and 2021.

Conclusion

Although settled cases of BDI have risen in the last 20 years despite improvement in training and techniques of cholecystectomy, they remain significantly below the anticipated numbers. Prompt recognition of anatomy and intraoperative complication as well as effective post-op management are essential for better patient outcomes and maintaining this low claim rate.

Surgeon training within the NHS is crucial but appropriate case selection is the key to patient safety. Laparoscopic cholecystectomy can be a complex operation, worsened by delays in treatment , requires an experienced UGI surgeon or supervision by a consultant and never considered simple or routine operation.
BN SO44 - Is routine histological analysis of excised gallbladders necessary?
Authors: Findlay Alasdair , Belk Lucy , Rotimi Olorunda , Hayden Jeremy
Published: November 2024

Background

Gallbladder cancer is rare representing <1% of annual cancer diagnoses in the UK. It is more common in females (2.4/100,000 vs 1/100,000) with a peak age incidence of 85–89-years. Our trust routinely histologically analyses all resected gallbladders, over 1000 per year, regardless of indication. Our pathologists estimate that each specimen costs £75 to analyse, reflecting an annual cost of over £80,000. A 2021 systematic review suggested selective histological analysis is safe, reduces laboratory burden and costs. We aimed to assess our centre’s cholecystectomy specimens to ascertain the incidental gallbladder cancer diagnoses and explore the possibility of selective analysis.

Method

A retrospective search of our pathology database was carried out for the terms “cancer” and “gallbladder” from 2015 to 2018 inclusive. After exclusion of non-gallbladder primary cancers, all selected cases electronic notes were retrospectively reviewed. The primary outcome was the incidental findings of gallbladder cancer. Secondary outcomes were the indications for surgery, intraoperative findings, histological macroscopic description, final diagnosis and further management where applicable.

Results

We identified 4421 gallbladder specimens of which 12 (0.27%) identified cancer. The ratio of female to male diagnoses was 5:1 and the median age was 73.5 years. Of the 12 cancers, 7 (0.16%) of these were incidental findings, with 5 having surgery for symptomatic gallstones and 2 for gallbladder polyps. The 5 symptomatic gallstones patients all had grossly abnormal macroscopic appearances of the serosa, dense adhesions or exudate; all were confirmed as gallbladder adenocarcinoma. Three patients were fit enough for limited liver resection.

Conclusion

Our results demonstrate that across four years the rate of incidental gallbladder adenocarcinoma diagnosed by cholecystectomy was 0.16%. In all non-polypoidal cases (0.11%), the gallbladder was macroscopically abnormal. This suggests that with careful criteria, selective gallbladder histological analysis may reduce laboratory burden and therefore costs associated with elective gallbladder surgery. With increasing emphasis to improve efficiency and rationalise healthcare spending, our results suggest that selective histological analysis may be safe and effective. However, given the consequences of missing a cancer diagnosis it would require a larger scale multi centre study to support a move in this direction.
BN SO48 - Antibiotic prescribing for elective inguinal hernia repairs
Authors: Mahmoud Salma , Sengupta Paulomi , Williams Rosana , Craddock Kate , Evans William
Published: November 2024

Background

Inguinal hernia repairs are a common procedure with over one million operations performed annually in Europe and the US. The European Hernia Society do not recommend the routine use of antibiotics in low-risk patients due to no significant benefit. They advise the consideration of prophylaxis for patients with risk factors including recurrence, age > 70 years or immunosuppression.

Many surgeons are using antibiotic prophylaxis in all patients. However, inappropriate antibiotic use contributes to increased antibiotic resistance and increased healthcare cost. Our trust guidelines recommend a single dose of Cefuroxime in all patients undergoing an inguinal hernia repair with mesh.

Method

The aim of the project was to determine the compliance with current trust guidelines regarding antibiotic use in elective inguinal hernia repair with mesh. We also aimed to report on antibiotic prescribing patterns.

Patients undergoing an elective inguinal hernia repair with mesh over a six-month period were identified. Data was collected retrospectively from electronic patient records and included patient’s age, if they were classed as high risk (age over 70, recurrence of hernia, diabetic, steroid therapy), if antibiotics were prescribed, and if so, which antibiotics were utilised.

Results

Eighty-five patients were included in the final data analysis. The median age of patients included was 67 years of age, and 93% were male. 41 patients were identified as high risk, and most patients were ASA II.

Our results reported that 48% of patients were prescribed prophylactic antibiotics at induction. However, only two patients were prescribed the correct antibiotic, as per trust guidelines. Most patients were prescribed Co-Amoxiclav (78%), with a range of other antibiotics being used, including Flucloxacillin, Clarithromycin and Metronidazole.

We identified 37% of high-risk patients were not prescribed antibiotics.

Conclusion

Our trust guidelines were not reflective of best practice and did not consider individual patient or procedure risk factors. We identified varied antibiotic prescribing patterns with low compliance to trust guidelines.

Utilising our findings, we have created new guidelines, which recommend that in low-risk patients, routine antibiotic prophylaxis is not required. However, in the presence of patient-related risk factors as mentioned above, then a single dose of Cefuroxime is recommended.

The updated guidelines will ensure good antimicrobial stewardship and reduce unnecessary antibiotic prescriptions. In addition, they accurately reflect the current evidence base surrounding antibiotic prophylaxis.
BN SO50 - The Resurgence of Veress Needle Insufflation: An Evaluation of Efficacy and Safety of One Surgeon’s Practice
Authors: Shivarajan Amber , Ballinger Claudia , Rohatgi Ashish
Published: November 2024

Background

Veress needle insufflation has been established as a safe and effective method of establishing pneumoperitoneum for laparoscopic surgery, with comparable risk profile to open methods. However, the blind nature of the procedure with potential complications such as iatrogenic bowel and blood vessel injury has seen this technique fall out of fashion with general surgeons. This study reviews the safety and efficacy of a single surgeon’s practice using Veress needle insufflation for Laparoscopic surgical procedures.

Method

A retrospective analysis was conducted on minimally invasive procedures performed between January 2019 and June 2024. In our practice, a standard or bariatric Veress needle is placed in a small incision at Palmer’s point. A manometer test is performed with CO2 insufflation at a low flow rate and raising the abdominal wall. If a low pressure is established, then the flow is increased to achieve adequate pneumoperitoneum before introduction of a midline 5mm camera port. Primary outcomes of this study include rate of conversion to open techniques (either Hasson’s or open cut down) and any complications.

Results

Of the 702 cases reviewed, five patients (0.71%) required conversion to open insufflation techniques. Two (0.28%) had bleeding from the omentum, and one patient (0.14%) experienced inadvertent bowel insufflation which was managed conservatively with no long-term morbidity. Notably there were no port site hernias.

Conclusion

This study supports the continued use of the Veress needle as a safe and effective method of insufflation in laparoscopic surgery. It offers minimal incision size, easier access in high BMI patients, and an alternative when adhesions and scarring limit access. Furthermore, adopting this technique can be particularly useful for appropriate port placement in robotic surgery, making it a valuable tool for modern surgical practices.
BN SO53 - Thoracotomy for the Repair of Giant Paraesophageal and Hiatal Hernias: A Systematic Review
Authors: Abdul Suhaib , Fernando John , Iftikhar Syed
Published: November 2024

Background

The utilisation of transthoracic approaches for the repair of large hiatus hernias remains a topic of clinical debate. This study aims to evaluate and compare the efficacy, safety, and recovery metrics for transthoracic hiatal hernia repair and comparisons to the laparoscopic approach.

Method

A literature search was conducted using the key terms "hiatus hernia," "thoracotomy," "thoracic approach," and "Belsey Mark IV." The databases searched included MEDLINE, EMBASE, and Web of Science, covering the period from 2000 to June 2024. Extracted data included patient demographics, study design characteristics, length of stay, complication rate and mortality rate.

Results

A total of 5 citations were selected comprising a total of 560 patients of which 164 were male (29.3%) with an overall mean age was 64.9 (pooled SD = 1.93) and weighted mean follow-up length was 56.4 months (pooled SD = 39.1 months). The weighted overall mean length of stay was 14.5 days (Pooled SD = 7.42). The overall rate of minor complications was 19% (95% CI [6%, 31%]). The overall rate of major complications was 13% (95% CI [6%, 21%]). There were 4 reported mortalities in total and an overall leak rate of 1% (95% CI [0%, 2%]).

Conclusion

Both thoracotomy and laparoscopy have unique benefits and risks in the context of hiatal hernia surgery. Access via thoracotomy is associated with a higher incidence of complications. However, for large or emergent paraesophageal hernias, the transthoracic approach may represent a viable option in select patients.
BN SO55 - Rare case of Ectopic pancreatitis in stomach and its Surgical Management
Authors: Abdul Suhaib , Nannyakkara Kushan , El-Sharkawy Ahmed , Leeder Paul
Published: November 2024

Background

This presentation covers the case of Mr. D, a 38-year-old male who presented with upper abdominal pain and vomiting, initially treated as gastritis but later developing more complex symptoms. This case highlights the diagnostic challenges and management of ectopic pancreatitis, a rare condition characterized by pancreatic tissue located outside its usual anatomical position.Mr. D, a personal trainer with a history of asthma and Meckel's diverticulum excision, experienced recurring epigastric pain, bloating, and early satiety. His pain was particularly related to eating, fasting and often disrupted his sleep. Despite treatment with proton pump inhibitors (PPIs), his symptoms persisted, prompting further investigation

Method

Initial investigations including ultrasound, chest X-ray, and ECG showed no significant abnormalities. However, subsequent gastroscopy and CT scans suggested a gastrointestinal stromal tumor (GIST), leading to referral for endoscopic ultrasound (EUS) and biopsy. The findings indicated a highly vascular, mixed echogenic lesion in the submucosa, likely a GIST, but initial biopsies were inconclusive

Results

Following conservative treatment, Mr. D's inflammation significantly reduced, though he experienced recurrent pain necessitating surgical intervention. Diagnostic laparoscopy and gastroscopy revealed extensive adhesions and an inflammatory mass. The patient underwent a pyloric-preserving sleeve gastrectomy, with histology confirming pancreatic heterotopia with inflammation and cystic degeneration. Post-operatively, Mr. D initially struggled with dietary intake but improved over time, tolerating a solid diet by the last follow-up.

Conclusion

This case underscores the complexity of diagnosing and managing rare conditions like ectopic pancreatitis. It highlights the importance of a multidisciplinary approach and the potential need for surgical intervention when conservative management fails. The presentation aims to provide valuable insights into the diagnostic process, the role of MDT discussions, and the therapeutic challenges associated with ectopic pancreatitis.
BN SO60 - Oesophageal physiology studies: Conversion to surgery
Authors: Davis Heather , Atkins Rosa , Browning Matthew , Yao Lu , Platt Timothy , Kostalas Marcos , Srinivas Gandrapu , Sinha Surajit , Christopoulos Petros , Andrews Stuart , Bowling Kirk
Published: November 2024

Background

This study aims to assess the proportion of patients that proceed to have hiatal surgery after oesophageal physiology studies. The results allow better planning in service development and workforce provision.

Approximately 25% of the adult population suffer reflux symptoms (1), however not all patients benefit from surgical intervention. UK data show 1693 anti-reflux operations and 740 hiatal hernia repairs took place 2022-2023 (2). Oesophageal physiology studies, i.e. high resolution pH manometry and 24-hour pH monitoring, are the gold standard investigation in such patients to determine diagnosis and guide management.

Method

All patients who underwent oesophageal physiology studies between January 2021 and December 2023 were assessed by case note analysis. All patients considered for surgery were discussed in our hiatal MDT. Whilst achalasia is relatively rare, these patients also pass through oesophageal physiology and so are also considered here. Patients with previous hiatal surgery were excluded (20 patients).

Results

182 patients attended; 137 underwent the tests, 22 tolerated manometry only, 5 underwent BRAVO.

78 were diagnosed with symptomatic/volume reflux, 3 with hiatus hernia. Mean DeMeester score was 47.63 (range 1.87-228.58) c.f. 20.2 (range 0.2-192.96) in the non-operative group.

Ten patients had achalasia; two were referred for POEM, one Botox and one awaits further investigation. Six underwent Heller’s cardiomyotomy and Dor fundoplication.

76 patients were offered surgical intervention for reflux and/or hiatus hernia; 10 of whom declined. 3 patients underwent surgery privately. To date 39 procedures have been completed. 16 patients await further tests.

Conclusion

42% of patients undergoing oesophageal studies were offered surgical intervention across a two-year period in our benign unit. A further 9% are awaiting outcome. The data suggest that when planning surgical services, finances and workforce we should anticipate approximately 40% of these patients will go on to require surgery.
BN SO61 - Modern Surgical Training: A Comparative Commentary
Authors: Davis Heather , Browning Matthew , Bowling Kirk
Published: November 2024

Background

Laparoscopic cholecystectomy is a cornerstone of benign upper GI surgery; approximately 3% of the population have symptomatic gallstones and over 61,000 laparoscopic cholecystectomies are performed every year in the UK (1). Whilst a relatively safe procedure, bile duct injury is an iatrogenic catastrophe with increased incidence according to the bile duct injury registry. We must consider if the requirements for completion of training (CCT) are robust enough. Indeed, non-surgeons have performed 170 laparoscopic cholecystectomies and would arguably meet the same requirements (2).

Method

Here we compare CCT requirements for general surgery with upper GI special interest with the requirements for certification in diagnostic endoscopy. This is a procedure performed by upper GI surgeons, with accreditation criteria determined by Joint Advisory Group (JAG) (3) rather than the Joint Committee on Surgical Training (4).

Results

CCT requires 110 cholecystectomies. Endoscopy requires 250 cases. Within the final 3 months of training, 95% of cases should be physically unassisted and D2 intubation and J manoeuvre should be achieved in 95% of 15 cases.

Endoscopy also requires five reflections and attendance of a basic skills course.

Cholecystectomy requires three level 4 PBAs (performed fluently without guidance or intervention). Endoscopy requires >25 DOPS with the 5 most recent scoring >90%. 4 summative DOPS must demonstrate competence for independent practice.

After CCT, consultants undergo appraisal. After JAG accreditation there is a defined period of supervision. 100 OGDs must be performed a year.

Conclusion

Diagnostic OGD is an arguably safer and more simple procedure than a laparoscopic cholecystectomy. However, accreditation requirements for each procedure are wildly different. Comparatively, laparoscopic cholecystectomy lacks stringent indices and has no ongoing accreditation requirements. We suggest that a more robust process might act to combat the increasing rate of life-changing bile duct injury during laparoscopic cholecystectomy.
HPB SO06 - An advanced clinical practitioner (ACP) led pancreatic cyst surveillance programme
Authors: Oakes Scott , Mahmood Sajjad , Lekharaju Venkata , Iqbal Javaid
Published: November 2024

Background

The prevalence of pancreatic cysts (PCs), including intraductal papillary mucous neoplasms (IPMNs), has increased substantially over recent decades. This rising prevalence is due largely to the increasing volume and quality of medical imaging technology.

Although PC's are often an incidental finding in asymptomatic individuals, a small number do harbour a certain malignant potential and thus raise warranted concern. The challenge therefore is identifying the high-risk lesions for early resection through robust, guideline-driven surveillance.

To ensure a consistent and evidence-based approach to PC surveillance, our trust has adopted a dedicated surveillance programme led by an Advanced Clinical Practitioner (ACP) in gastroenterology.

Method

A PC surveillance clinic was designed and delivered from April 2023. The service underwent a formal inauguration and was promoted at the regional HPB MDT. All patients receive a standardised approach to surveillance in-line with the current international guidelines or regional MDT recommendation. Surveillance diagnostics are arranged by the ACP and patients are updated with regard to their results and next steps during a telephone or face-to-face consultation. A robust database was designed to capture relevant patient details and serve as a future research aid.

Results

144 referrals have been received (04/23-04/24). 134 are undergoing surveillance, with discontinuation due to frailty, patient choice, diagnosis of an inflammatory cyst or relocation in 10 cases.

Most PCs under surveillance are side-branch IPMNs (70.9%). Malignant transformation has not yet been observed, however 18 cases display worrisome features and 3 have high-risk stigmata. These are undergoing intensive surveillance or awaiting MDT discussion.

93% of surveyed patients (16) report a greater sense of involvement in their PC surveillance and a greater awareness of their surveillance protocol (93%). Referrer feedback (7) has been positive and staff are satisfied with this service (100%).

Conclusion

Robust surveillance of patients with PC will likely improve early detection and prognosis of pancreatic cancer by enabling early identification of resectable cases. A centralised service that adopts a single agreed guideline will reduce variation in the management of these cysts, ensure these complex lesions are under specialist observation and offer a single point of contact which will improve retainment and follow-up of these patients.

It is intended that synchronous data collection will serve to generate a comprehensive repository of information relating to PC. This databases will aid future research into this evolving field and steer future guideline development.
HPB SO10 - Evaluation of the impact of an Enhanced Recovery Pathway on clinical outcomes after Pancreaticoduodenectomy
Authors: Ugur Suha , Clarke Hannah , Fraser Jason , Armstrong Thomas , Hamady Zaed , Karavias Dimitrios , Pike Thomas , Takhar Arjun , Arshad Ali
Published: November 2024

Background

Southampton General Hospital (SGH) is a high-volume HPB centre with a well-established Enhanced Recovery After Surgery pathway (ERAS). Despite the morbidity associated with pancreatic surgery, there is a large body of evidence supporting the use of a multi-modal approach to accelerate patient recovery. Within SGH, ERAS is utilised for all patients undergoing Pancreaticoduodenectomy (PD). Initial assessment of the pathway in SGH demonstrated a reduction in length of stay. Since its implementation, ERAS has been modified to optimise the pathway. The aim of this study was to assess whether the impact of ERAS had progressed over time.

Method

Single centre retrospective analysis of patients undergoing open PD from 2007-2023. Pancreatic reconstruction was with pancreaticojejunostomy. Pre and Post ERAS data were analysed. Post ERAS data was subdivided into Early, Middle and Late implementation time phases. Length of Stay, Complications (Clavien-Dindo Grade 3 and above), Readmissions and Mortality were all examined. Non-parametric data analysis was undertaken with Kruskal-Wallis, Spearman rank correlation and Wilcoxon rank-sum tests. Significance further assessed with Multi-variate regression (MVR). All Data were analysed using STATA.

Results

Overall, 861 patients underwent an open PD, the yearly volume increasing with time. Mean age was 66 years, which did not change with time. With ERAS implementation, Median Length of Stay (LOS) fell 13 to 9 days (p<0.01) and there was no statistically significant increase in Grade 3 complications or Readmissions (p=0.931, p=0.163). Grade 3 complications increased LOS (p<0.01). Increased age led to a small increase in LOS (p<0.01). Median LOS across Early, Middle and Late ERAS periods was 10, 9 and 9 respectively. LOS did not consistently demonstrate a statistically significant improvement across ERAS phases (MVR p=0.387, K-Wallis p<0.05).

Conclusion

The implementation of ERAS significantly reduced the median LOS for patients undergoing PD, without increasing their risk of complications or readmissions. This benefit has also been safely maintained across the period of its implementation.