bluuebunny/crossref_metadata_2025 huggingface dataset:
O-B04 The effect of high fat diet and subsequent intentional weight loss on tumour burden in an animal model of spontaneous endometrial cancer
Authors: Sinclair Piriyah , Wilkinson Michael , Conroy Emer , Downey Paul , Gallagher William , Docherty Neil , Roux Carel le , Brennan Donal
Published: December 2021

Background

Obesity drives endometrial cancer (EC). Metabolic surgery (MS) induces sustained weight loss, reduces EC risk and has been shown to reverse histological changes of endometrial hyperplasia. One mechanism is increased GLP-1 post surgery. Few interventional studies have been conducted in the BDII/Han rat; an animal model of spontaneous EC. This study aimed to examine whether high fat diet (HFD) and weight gain, as well as subsequent intentional weight loss using Liraglutide (a GLP-1 receptor agonist) alters EC tumour biology and burden in the BDII/Han rat. A rat imaging protocol was validated to assess development and longitudinally track tumours.

Methods

An imaging protocol was developed and validated. 7 BDII/Han rats were fed normal chow (NC) and 8 weight-matched rats fed HFD from 3 months of age. Longitudinal PET-CT was conducted at 7, 9, 12 and 15 months. Abdominal visceral fat was analysed from L1-L5 on CT. Subsequently, an intervention study compared the 8 HFD-Control rats to 8 weight-matched HFD-fed rats treated with Liraglutide from 12-15 months. PET-CT was used to assess disease progression. Analysis of histological, immunohistochemical and transcriptomic parameters were used to compare cohorts. All rats were euthanased aged 15-months. Imaging was correlated with necropsy findings and histopathology.

Results

HFD rats had more abdominal fat on CT imaging (8.6cm3±0.7vs4.0cm3±0.6;p<0.0005) and 10% higher body-weight than NC rats (232.5g±4.9vs209.4g±2.0;p=0.001) at the study end. Histopathology demonstrated EC in 57%(n = 4) of NC and 50%(n = 4) of HFD rats. PET-CT was 87.5% sensitive and 86% specific. Liraglutide induced significant reduction in final body weight (208.3g±5.7vs232.5g±4.9;p=0.006) and abdominal fat on CT compared to controls (4.4cm3±0.4vs8.6cm3±0.7; p=0.0001). 2 tumours were identified in the Liraglutide group (25%) compared to 4 in the control group (50%). GLP-1 receptor expression was not detected in benign or malignant BDII/Han uterine tissue.

Conclusions

This study has established a safe, sensitive and specific imaging protocol for longitudinal assessment of EC progression in BDII/Han rats. The HFD intervention used did not accelerate EC burden. However, it did create an obese phenotype and gave new information on the pathological variations of EC in the BDII/Han rat. Intentional weight loss from Liraglutide halved EC burden compared to controls in this study. An absence of GLP-1R expression may suggest weight loss dependent mechanisms. This novel pilot study is a foundation for future studies assessing the effect of intentional weight loss using metabolic surgery in obesity-related cancer.
O-BN01 The para-oesophageal hernia symptom tool (post): A modified delphi consensus study
Authors: Puri Aiysha , Patel Nikhil , Sounderajah Viknesh , Ferri Lorenzo , Griffiths Ewen , Low Donald , Maynard Nick , Mueller Carmen , Pera Manuel , van Berge Henegouwen Mark , Watson David , Zaninotto Giovanni , Hanna George , Markar Sheraz
Published: December 2021

Background

Patients with a para-oesophageal hernia (POH) report a complex range of symptoms and quality of life (QOL) issues. Clinicians often utilise existing health related quality of life tools to (1) identify patients who are eligible for surgical management and (2) to evaluate the benefit of surgical intervention. However, the most commonly used tools for this purpose are not disease specific. As such, crucial POH specific symptoms which impact QOL may not be captured. In order to address this issue, a modified Delphi consensus study was undertaken to establish a HRQOL instrument specific to POH.

Methods

A two-round modified Delphi consensus study was conducted with a group of international experts. Participants were identified through (1) their authorship in landmark POH studies and (2) the professional networks of the study investigators. Prior to the Delphi process, a scoping survey was undertaken in order to generate a list of candidate items. Participants were asked to rate the items’ importance in assessing patients with POH using a 5-point Likert scale. The a priori threshold for inclusion was 80% for scores of 4 or 5. If consensus was not achieved, the item was carried through to the next round.

Results

The candidate list of items consisted of 64 symptoms, refined to 20 for inclusion within the first modified Delphi round. Four symptoms; ‘difficulty getting solid foods down’, ‘chest pain after meals’, ‘difficulty getting liquids down’ and ‘shortness of breath only after meals’, reached consensus threshold of 80% in the first round and one additional symptom, ‘early feeling of fullness after eating’, reached consensus in the second. A total of 26 participants took part in the first and 24 in the second round. These five symptoms have been identified to form the initial version of the Para-Oesophageal Hernia Symptom Tool (POST).

Conclusions

POST is the first tool that aims to capture POH-specific symptoms that impact upon HRQOL. Prior to clinical use, this tool will be presented in international patient workshops to assess its construct validity. Following this, we aim to assess the content validity of the tool through a longitudinal study in a cohort of patients with POH who are undergoing repair. We hope that this tool will serve as a decision support tool for clinicians who are evaluating the risk-benefit of surgical intervention in this cohort of patients.
O-BN07 Transesophageal Endoscopic Resection of Mediastinal Cysts
Authors: Ma Li-yun , Liu Zu-qiang , Chen Wei-feng , Li Quan-lin , Zhou Ping-hong
Published: December 2021

Background

Primary mediastinal cysts are infrequent lesions derived from a variety of mediastinal organs or structures. Complete surgical resection is the treatment of choice even in asymptomatic patients to prevent severe adverse events (AEs) and establish the diagnosis. Transesophageal endoscopic resection of benign mediastinal tumors has been proven feasible. The aim of this study is to evaluate the feasibility, safety and efficacy of transesophageal endoscopic surgery for mediastinal cysts.

Methods

From January 2016 to May 2021, patients with mediastinal cysts who underwent transesophageal endoscopic resection were retrospectively included. Clinicopathological characteristics, procedure-related parameters, AEs, and follow-up outcomes were analyzed.

Results

A total of 10 patients with mediastinal cysts were included in this study. The mean cyst size was 3.3±1.3 cm. Histopathology revealed 3 bronchogenic cysts (30.0%), 4 esophageal duplication cysts (40.0%), 2 gastroenteric cysts (20.0%), and 1 lymphatic cyst (10.0%). All procedures were performed uneventfully. En bloc resection was achieved in 6 patients (60.0%). Aggressive resection was avoided to prevent damage to the surrounding vital organs. Mean procedure time was 63.4±36.5 min. No major pneumothorax, bleeding, mucosal injury or fistula occurred. One patient had a transient febrile episode (>38.5 °C). Mean postoperative hospital stay was 2.7±0.9 days. No residual or recurrent lesions were observed in any patient during a mean follow-up period of 29.8±19.5 months.

Conclusions

Transesophageal endoscopic surgery appears to be a feasible, safe, effective and much less invasive approach for mediastinal cyst resection. Larger prospective studies are required to fully assess the efficacy and safety of this novel technique.
O-EGS02 Effective use of afternoon Day Case Theatre Lists for Emergency Laparoscopic Cholecystectomy on Emergency Surgery Ambulatory Care (ESAC) Pathway
Authors: Wei Rui , Shahid Mishal , Barton Jessica , Williams Lian , Hollyman Marianne
Published: December 2021

Background

Gallstone disease is a common entity and affects up to 10-15% of the European population. The majority of these cases are asymptomatic but approximately 20% will develop complications such as severe biliary colic, cholecystitis, choledocholithiasis and pancreatitis. Early cholecystectomy in patients suffering from symptomatic gallstones can improve post-operative outcomes, avoid re-attendance and reduce overall length of hospital stay. We describe how two afternoon day case theatre lists were successfully utilised to prevent surgical admissions by enabling laparoscopic cholecystectomy on an urgent basis.

Methods

A sustainable pathway for symptomatic gallstones was introduced to Emergency Surgery Ambulatory Care (ESAC). Patients presenting with acute symptoms, well enough for ambulatory care, were referred to ESAC for diagnosis and management. Patients fit for surgery underwent pre-operative assessment before being operated on one of two weekly afternoon lists. A standardised, evidence-based approach was used for all laparoscopic cholecystectomies to ensure homogeneity of technique and patient care. This included pre-incision local anaesthetic, low flow and pressures intra-operatively, adequate analgesia to-take-home, and follow-up telephone consultation at 48hrs. Prospective data collection began in 2019 looking at hospital admission rate and 30-day re-presentation.

Results

Analysis was performed on data collected from September 2019 to July 2021. 151 patients had laparoscopic cholecystectomies, 107 were female and 44 male. Age range was 18-83 (median age 49) and median time to operation was 3 days. Overall, the spectrum of gallstone disease was 81 biliary colic, 44 cholecystitis, 20 pancreatitis and 6 choledocholithiasis. 18 patients were admitted post-operatively with length of stay ranging 1-6 days (median 1.5 days). 17 patients re-presented within 30 days, mainly for abdominal or pleuritic chest pain, although one patient required ERCP for CBD stones and another had pancreatitis.

Conclusions

Emergency surgery for symptomatic gallstone disease can be performed successfully on a day case basis. At our centre, the rate of post-operative admission was 12% and 30-day re-presentation was 11%. Standardisation of referrals, assessment and operative technique can achieve excellent outcomes with low rates of hospital admission and post-operative complications.
O-EGS03 Laparoscopic surgery versus Endoscopy in the management Common Bile Duct Stones: systematic review and Meta-analysis
Authors: Elhag Hafs , Eltayeb Omar
Published: December 2021

Background

With the advancement in minimally invasive surgery, a 1 stage Laparoscopic Common Bile Duct Exploration (LCBDE) followed by Laparoscopic Cholecystectomy (LC) is a great alternative to removing the gallbladder and CBD stones provided the surgeon possesses the necessary skills. The current guidelines for managing CBD stones is the 2 stage approach, Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by (LC). The objective of this study is to assess whether LCBDE+LC should be the gold standard in managing CBD stones by comparing the clearance rate of common bile duct stones, morbidity, mortality, and the duration of hospital stay with ERCP+LC.

Methods

This is a systematic review with a meta-analysis that included RCTs of patients who were treated by the LCBDE/LC versus ERCP+LC. The PRISMA guidelines for reporting systemic reviews were followed. RCTs were collected by 2 authors Independently from Cochrane Central Register of Controlled Trials, Medline and Embase. Statistical analysis was carried out by a computer application called Review Manager using the Mantel–Haenszel method, the results were then plotted on a Forest Plot diagram and the 2 groups were then compared.

Results

849 patients from 7 RCTs were included in the study, 426 patients in the ERCP+LC arm and 423 in the LCBDE/LC arm. According to the Meta-analysis, Laparoscopic Common Bile Duct Exploration with Cholecystectomy was significantly superior to ERCP + LC in terms of successful Clearance of CBD stone, mortality rate, and Acute Pancreatitis. but had significantly higher rates in biliary leakages. There were no significant differences in Surgical Site Infections, Haemorrhages, Acute Cholangitis, Perforations, or duration of hospital stay between the two arms.

Conclusions

The current evidence suggests that LCBDE/LC is superior in successful CBD stone clearance, mortality, and acute pancreatitis. However, further RCTs will be needed to assess overall Morbidity, surgical site infections, Haemorrhages, Acute Cholangitis, perforations, or duration of hospital stay. The current guidelines must be reviewed to consider LCBDE/LC as the gold standard in managing patients with CBD stones.
O-EGS04 Is group and save necessary for all patients undergoing emergency cholecystectomy: A 6-year retrospective audit
Authors: Kuan Jen Yee , Mohammed Ahmed , Rajendran Ilayaraja , Turner Paul , Ball Christopher , Date Ravindra , Krishnamohan Nitya , Ward Jeremy , Pursnani Kishore , Shetty Vinutha Daya
Published: December 2021

Background

Emergency cholecystectomy (EC) has a low perioperative bleeding risk. There is no current national guideline to suggest routine preoperative Group and Save (G&S) is necessary. Our Trust guideline recommends preoperative G&S for all EC operations. In 2018, a Trust-wide policy was adopted based on an audit, which concluded that routine preoperative G&S is unnecessary for elective cholecystectomy. All G&S require 2samples taken separately, which can delay surgery. The cost to process one sample for G&S is £28. Therefore, a study was set up to assess the need for routine G&S in patients undergoing EC.

Methods

This retrospective observational study was based on a prospectively collected hospital database from March 2015 to March 2021 using MS-Excel. All patients who underwent EC (laparoscopic and/or open) within 10 days during index admission were included. All elective cholecystectomies were excluded. Patients were divided into GS-patients (patients with G&S) and NGS-patients (patients without G&S). The primary outcome is the difference between the incidence of ‘Perioperative blood transfusion’ (PBT) between the studied groups. The overall cost-effectiveness is considered as a secondary outcome. The categorical data were analysed using the Chi-square test; a p-value <0.05 is considered statistically significant.

Results

In this 6year period, 2210patients underwent cholecystectomy. Of these, 496patients (22.4%) who underwent EC were included. 447patients (90.1%) were in GS group and 49patients (9.9%) were in the NGS group. None from the NGS group required PBT, whereas 3patients (0.6%) in the GS group received blood transfusion. However, PBT was truly indicated in 1patient due to the associated cardiovascular comorbidities. On the contrary, 2patients did not fit the ‘restrictive transfusion threshold’ criteria of JPAC. There was no statistically significant difference in PBT requirement between the studied groups (p = 0.331). Deferring routine G&S for EC could have saved our institution £24,976.

Conclusions

Our study has demonstrated that preoperative G&S is not indicated for all emergency cholecystectomies. It takes approximately 1 hour for G&S to be processed unless crossmatching is required. Group O-negative or O-positive blood can be provided to patients when urgent blood transfusion is needed depending on their age and gender. Thus, we conclude that G&S should be restricted to patients with low preoperative haemoglobin, bleeding and clotting disorders, those known to have abnormal blood antibodies and significant cardiovascular comorbidities.
O-EGS05 The Prevalence of Bile Duct Stones in Patients Presenting with Acute Pancreatitis vs. Jaundice in a 5774 patient series. The Case for Single Session Surgical Management
Authors: Nassar Ahmad H m , Kilpatrick Rhona , Sallam Mahmoud , Ali Kiren
Published: December 2021

Background

There is increasing evidence that single session laparoscopic cholecystectomy with cholangiography and, when necessary and available, bile duct exploration offers optimal clinical outcomes and superior cost benefits to patients with suspected bile duct stones.

There is a perception that preoperative endoscopic clearance of bile duct stones is necessary in patients presenting with pancreatitis and jaundice. However, most patients do not have severe disease and are fit for index admission surgical management. We aim to study the prevalence of bile duct stones in pancreatitis vs. jaundice and evaluate this management approach with regards to preoperative and operative parameters and postoperative outcomes.

Methods

Analysis of prospectively maintained database of 5774 consecutive laparoscopic cholecystectomies, cholangiography(IOC) with or without bile duct exploration was undertaken. Patients with suspected bile duct stones are referred to one firm with an intention of single surgical treatment in the index admission. Data of patients presenting with acute pancreatitis and obstructive jaundice was extracted. In the absence of suspected malignancy there was a limited role for preoperative MRCP and ERCP. The incidence of confirmed CBD stones requiring exploration, type of exploration, morbidity, re-operations and readmissions, hospital stay, number of episodes, and presentation to resolution intervals were compared in the two groups.

Results

Conclusions

Single session surgical treatment of patients with acute pancreatitis and jaundice by specialist firms in the index admission (89% and 86% if previous admissions by other units is excluded) offers many advantages. MRCP and ERCP utilisation is minimised in favour of IOC; two thirds of pancreatitis patients and one third of jaundiced patients have no CBD stones. Simple transcystic explorations deals with most stones in both groups. The morbidity, open conversion, readmissions, retained stones and re-operations are low. Total hospital stay, number of treatment episodes and presentation to resolution are optimised and should persuade surgeons to avoid subjecting patients to multiple treatments.
O-L01 Learning curve for laparoscopic liver resection: does it affect survival in colorectal liver metastasis?
Authors: Shanti Hiba , Raman Rakesh , Chakravartty Saurav , Belgaumkar Ajay P. , Patel Ameet G.
Published: December 2021

Background

After Gagner introduced laparoscopic liver resection (LLR) in 1992, it was not until 2004 that the first series with more than ten laparoscopic major liver resections was reported. Furthermore, a multicentre study by Allard et al., in 2015 revealed that laparoscopy was only used in 176 (6.7%) patients out of a total of 2620 patients treated for colorectal liver metastasis (CRLM). This lag time in the establishment of LLR was attributed to the steep learning curve (LC) due to technical complexity and caution about oncological safety. The aim of this study is to assess if the learning curve of LLR has affected survival of patients with CRLM.

Methods

All consecutive LLR performed by a single surgeon between 2000–2019 were retrospectively analysed. RA-CUSUM for conversion rate and the log regression analysis of the blood loss were used to identify two phases in the learning curve. LC was then applied to CRLM patients and the two subgroups were compared for oncological and survival outcomes. The analysis was repeated with propensity score-matched (PSM) groups

Results

A total of 286 patients were included in the learning curve analysis. Combining the results from the RA-CUSUM and the blood loss log curve identified two distinct phases in the learning curve. The early phase (EP, n = 68) represented the initial learning experience, and the late phase (LP, n = 218) represented increased competence and the introduction of more challenging cases.

The LC was applied to 192 patients with colorectal liver metastasis (EPc n = 45, LPc n = 147). R0 resection was achieved in 93%; 100% in EPc and 90% in LPc (P = .02). The cohort median overall survival (OS) and was 60 months. The median recurrence-free survival (RFS) was 16 months. The 5- year OS and RFS were 51% and 33%, respectively. The overall and recurrence-free survival rates were not compromised by the learning curve; OS (HR: 0.78, 95% CI 0.51-1.2, p = .26), RFS (HR: 0.94, 95 % CI 0.64-1.37, p=.76). Results were replicated after PSM.

Conclusions

In our experience, the development of a laparoscopic liver resection program can be achieved without adverse effect on the long-term survival in CRLM.
O-L02 Evaluation of the Utility of Prognostic Models for Patients Diagnosed with Peri-hilar Cholangiocarcinoma
Authors: Manu Nichola , Bird Nicholas , Gilbert Timothy , Quinn Marc , Jones Robert , Diez-Nieto Rafa , Fenwick Stephen , Malik Hassan
Published: December 2021

Background

Several potential prognostic models have been developed to stratify patients with peri-hilar cholangiocarcinoma (PHC) by Overall Survival (OS). The American Joint Committee on Cancer (AJCC) staging system is a post-resectional model utilising tumour-specific pathological parameters to stratify and predict OS. The Mayo Clinical (MC) scoring system has been developed utilising primarily clinical, serological, and radiological variables to predict survival in all patients with a diagnosis of peri-hilar cholangiocarcinoma. The objective of this study was to evaluate the utility of these models in determining prognosis for all patients presenting to a tertiary treatment centre with PHC.

Methods

Three hundred and two patients diagnosed with PHC referred to a regional tertiary referral centre between 2008 and 2019 had their demographic and survival data retrospectively analysed from a prospectively held database linked to Hospital Episode Statistics and Somerset Cancer Registry data. One hundred and twenty seven patients were surgically explored. Eight-four patients underwent resection. One-hundred and seventy-four (57.6%) patients underwent palliative endoscopic therapy. Univariate and multivariate modelling was utilised to determine significant prognostic variables. Concordance Indices (C-Indices) were constructed for the prognostic models to determine internal validity within the cohort.

Results

Multivariate analysis demonstrated that: pre-interventional ECOG status (p < 0.001); serum albumin (p < 0.001); bilirubin levels (p < 0.001); CA 19-9 levels (p < 0.001) and resectional status (p < 0.001) were significant predictors of OS. Patients stratified by the MC scoring system to early-stage disease had a significantly longer OS compared to patients fulfilling late-stage criteria (p < 0.001). The predictive C-Indices for the MC model obtained significance in discriminating OS for the entire cohort (p < 0.05) and un-resected patients (p < 0.05). Neither model attained significant concordance for accurately discriminating OS in post-resectional patients.

Conclusions

The predictive performance of the stated prognostic models for OS have poor utility. Simple pre-interventional serological, functional and radiological variables appear to provide better prognostic indication of OS. Variables not incorporated in the AJCC registry have a significant effect upon post-resectional OS and require full incorporation in to model prognostication.
O-L07 Role of liver resection for metastases from uveal melanoma: Experience from a supra-regional centre, current evidence, and future prospects
Authors: Trivedi Dharmadev , Aldulaimi Natasha , Karydis Ioannis , Wheater Matthew , Modi Sachin , Stedman Brian , Karavias Dimitrios , Primrose John , Pearce Neil , Takhar Arjun
Published: December 2021

Background

Management of liver metastases from uveal melanoma (LMUM) requires a ‘multi-modal’ approach including surgical resection. This study aimed to evaluate the role, safety, and oncological effectiveness of liver surgery for patients with LMUM in the context multidisciplinary management. A comprehensive treatment pathway developed upon current published evidence, prevalent national guidelines and novel treatment options is presented (Figure 2)

Methods

Retrospective review of prospectively maintained database between February 2005 to August 2018 was performed using the institutional electronic patient record system from oncology and surgical department. Demographic data, MDT outcome letters, operative records, clinic letters, letters from referring hospitals, discharge summaries, radiology reports, and histology findings were reviewed. Focused literature review was conducted to identify all relevant publications. All advanced statistical analysis was performed using SPSS version 27.0 software (IBM Corp., Armonk, NY, USA). A p-value of < 0.05 was considered to be statistically significant. The work was approved by the institutional clinical governance department (Audit ID 6661).

Results

31 patients underwent diagnostic laparoscopy and 17 patients received 19 liver resections locally (Figure 1). 7 major (≥ 3 seg) and 12 minor liver resections (14 laparoscopic) were done without any mortality or major complications. 10/19 (52.6%) were R0 resections. Overall survival positively correlated with the time from UM to LMUM (rs = 0.859, p<0.0001). R0 or R1 resection margin status did not significantly influence survival outcomes (OS 25 Vs 28, p = 0.404; RFS 13 Vs 6 months, p = 0.596), though R1 cohort had longer lead time (100 Vs 24 months, p = 0.0408).

Conclusions

Liver resection for LMUM is safe, effective and complements multimodal management. Lead time from development of UM to LMUM remains a key factor affecting survival outcomes. As novel treatment modalities for regional and systemic disease control for metastatic uveal melanoma continue to develop, surgical intervention will also continue to evolve as part of the multi-disciplinary management. We emphasise the need for developing a collaborative database at a national and international level. We present an evidence-based, multi-disciplinary management pathway for LMUM patients (Figure 2).
O-OGC03 Real-time tracking and classification of tumour and non-tumour tissue in upper gastrointestinal cancer specimens using diffuse reflectance spectroscopy
Authors: Nazarian Scarlet , Gkouzionis Ioannis , Kawka Michal , Patel Nisha , Darzi Ara , Elson Daniel , Peters Christopher
Published: December 2021

Background

Diffuse reflectance spectroscopy (DRS) is a technique that allows discrimination of normal and abnormal tissue based on spectral data. It is a promising technique for cancer margin assessment. However, application in a clinical setting is limited by the inability of DRS to mark the tissue that has been scanned and its lack of continuous real-time spectral measurements. This aim of this study was to develop a real-time tracking system to enable localisation of the tip of a handheld DRS probe to aid classification of tumour and non-tumour tissue.

Methods

A coloured marker was attached to the DRS fibre probe and was detected using colour segmentation. A Kalman filter was used to estimate the probe’s tip position during scanning of the tissue specimen. In this way, the system was robust to partial occlusion allowing real-time detection and tracking. Supervised classification algorithms were used for the discrimination between tumour and non-tumour tissue, and evaluated in terms of overall accuracy, sensitivity, specificity, and the area under the curve (AUC). A live augmented view with all the tracked and classified optical biopsy sites were presented, providing visual feedback to the surgeons.

Results

A green coloured marker was successfully used to track the DRS probe. The measured root mean square error of probe tip tracking was 1.18±0.58mm and 1.05±0.28mm for the X and Y directions, respectively, whilst the maximum measured error was 1.76mm. Overall, 47 distinct sets of tumour and non-tumour tissue data were recorded through real-time tracking of ex vivo oesophageal and gastric tissue. The overall diagnostic accuracy of the system to classify tumour and non-tumour tissue in real-time was 94% for stomach and 96% for the oesophagus.

Conclusions

We have been able to successfully develop a real-time tracking system for a DRS probe when used on stomach and oesophageal tissue for tumour detection, and the accuracy derived demonstrates the strength and clinical value of the technique. The method allows real-time tracking and classification with short data acquisition time to aid margin assessment in cancer resection surgery.
O-P02 A fast-track surgery programme leads to timelier treatment and higher resection rates in pancreatic cancer
Authors: Carino Nicola de Liguori , Baltatzis Minas , Maroso Fabio , Spiers Harry VM , Deshpande Rahul , Jamdar Saurabh , Satyadas Thomas , Sheen Aali J , Siriwardena Ajith K , O'Reilly Derek A
Published: December 2021

Background

Pancreatic cancer is currently the fourth most common cause of cancer-related mortality in the economically developed world and is set to become the second most common cause of cancer-related mortality within the next few years. NICE guidance makes a strong recommendation to offer up-front surgery to people with resectable pancreatic cancer, without preoperative biliary drainage, if sufficiently fit for surgery. The aim of this study was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting, to examine perioperative outcomes and to perform an intention to treat analysis to evaluate long-term survival between the two groups.

Methods

This was an observational study of a cohort of consecutive patients presenting with obstructive jaundice and undergoing pancreatoduodenectomy for pancreatic and periampullary malignancies between November 2015 and May 2019. Data related to patient and tumour characteristics, biliary drainage, surgery and histopathology were gathered and analysed from a prospectively maintained electronic database. Post-operative complications were defined and graded according to the definitions of the International Study Group on Pancreatic Surgery (ISGPS) and the Clavien-Dindo system. Data related to adjuvant treatment, disease recurrence and overall survival were also analysed.

Results

In this retrospective study of 216 consecutive operable patients, 70 followed the fast-track (FT) pathway and 146 had pre-operative biliary drainage (PBD). All 70 patients in the fast-track group and 122 out of 146 in the PBD group proceeded to surgery (100% and 83.6% respectively, p = 0.001). Interval time from diagnostic CT scan to surgery and from MDT decision to treat to surgery was much shorter in the FT group (median range) 8 vs 43 days p < 0.001 and 3 vs 36 days p < 0.001 respectively) as was the overall time from diagnostic CT to adjuvant treatment (88 vs 121 days p < 0.001). Postoperative outcomes including in-hospital stay, number and grading of complications, readmission rate and mortality rates were comparable in the two groups. There was no difference in survival between the two groups.

Conclusions

These data strengthen the existing evidence that, for a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage. The optimal comparison to the neoadjuvant approach is upfront fast-track surgery without biliary drainage followed by adjuvant therapy.
P-BN04 Evaluation of Outcomes of Anti-reflux Surgery in a District General Hospital
Authors: Lim Jie , Dronamraju Shridhar , Nachimuthu Senthil
Published: December 2021

Background

Gastro-oesophageal reflux disease (GORD) affects up to 20% of the Western population, and is usually associated with presence of hiatus hernia (HH). Proton pump inhibitors (PPI) are the mainstay treatment, but half of PPI users have persistent symptoms. Anti-reflux surgery in the form of fundoplication surgery with HH repair can be considered in patients unable to tolerate or unwilling to persevere with long term medical therapy and those with severe sequalae of reflux, such as those with  Barrett esophagus or non-healing erosive esophagitis. We aim to evaluate the outcomes and factors relating to surgical success of anti-reflux surgery.

Methods

We identified patients who had HH repair and fundoplication surgery from our prospectively maintained theatre database over a eight year period. Retrospective data collection was performed, inclusive of patients’ pre-operative investigations, intraoperative findings and postoperative patient outcomes. Chi Square and Mann Whitney U test were used to calculate the statistical significance. 187 cases were analyzed, involving only 167 unique patients as 14 patients had 1 redo surgery and 2 patients had 2 redo surgeries.

Results

Male to female ratio was 2:3. Median age was 59 years and median BMI was 29.1. 85% of cases were performed laparoscopically, which had the shorter median length of stay at 2 days. Pre-operative assessment of HH size with barium swallow had the highest sensitivity (82%) and specificity (75%). Large to moderate HH are more prevalent in female patients.  Rolling HH are more associated with dysphagia and vomiting  whereas sliding HH with reflux symptoms. Rolling HH are more likely to be repaired with an open approach and more likely to require hiatal mesh repair compared to sliding HH.

Conclusions

In the 96% of patients followed up, we successfully achieved symptom control in 94% of them. Although we were unable to find specific patient or surgical factors contributing to symptom recurrence or redo surgeries, we were able to identify certain pre-operative tests which can predict the difficulty of surgery. Larger scale case series would allow us to predict patient cohort at a higher risk of unsuccessful anti-reflux surgery.
P-BN06 Percutaneous cholecystostomy rates are increased following COVID-19 induced disruption to elective surgical pathways
Authors: Abdeen Bashar , Vulliamy Paul , English William , Bellam-Premnath Krsihna , Mansuri Ahmer , Mukherjee Dipankar
Published: December 2021

Background

The COVID-19 pandemic has led to major service disruptions, including the cessation of elective laparoscopic cholecystectomies (LC), causing delays in managing symptomatic gallstones. We hypothesised that this would lead to an increased need for percutaneous cholecystostomy (PC) for acute cholecystitis.

Methods

We performed a retrospective cohort study in a single NHS trust. We included all patients who underwent either LC or PC during the periods of March 1st – August 31st over the years 2019 and 2020. Patient data was obtained from prospectively maintained patient electronic notes. Data are presented as median and interquartile ranges for continuous data and the percentages for categorical data and compared with Mann-Whitney U-test and Fisher’s exact tests respectively.

Results

We observed a substantial reduction in the number of LC performed in 2020 (n = 99) compared to 2019 (n = 198), whilst the number of PC performed in 2020 (n = 35) was more than double that in 2019 (n = 17) (Fig.1). This increase in numbers persisted even after our LC service was restarted. Comparing the patients who underwent PC in both years, there were no significant differences in age (2019: 68 (45-76) vs 2020: 72 (57-81), p = 0.41),  comorbidities (Charlson comorbidity index≥4: 10 (59%) vs 16 (46%), p = 0.56), or in-hospital mortality (2019: 2 (12%) vs 2020: 3 (9%), p = 0.99). As a proportion of all biliary interventions for cholelithiasis, PC increased from 8% (17/214) in 2019 to 26% (35/134) in 2020 (p < 0.001).

Conclusions

These results show how the cessation of LC service was directly related to increased numbers of invasive ‘damage control’ procedures for acute cholecystitis, emphasising the importance of maintaining COVID-secure surgical pathways. The numbers of PC remained high even after the restart of LC service, consistent with a ‘COVID shadow’ resulting from interruptions to elective services that impacts patient care for a prolonged period.
P-BN09 Management of isolated splenic vein thrombosis: Risks and benefits of Anticoagulation
Authors: Eltweri Amar M , Basamh Mohammed , Ting Ying Yang , Harris Mark , Garcea Giuseppe , Kuan Li Lian
Published: December 2021

Background

Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalization does not occur. There is a wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalization rates and subsequent variceal bleeding risk.  

Methods

A retrospective cohort study including all patients diagnosed with iSVT on CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis, and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalization rates, risk of bleeding, and progression to portal vein thrombosis were examined.

Results

Ninety-eight patients with iSVT were included; of which thirty-nine patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalization rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less among patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation.

Conclusions

The current data support that therapeutic anticoagulation is associated with a statistically significant increase in recanalization rates of the splenic vein; with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomized clinical trials.
P-BN31 Surveillance for Gallbladder polyps at a NHS District General Hospital – a retrospective analysis
Authors: Khan Sharib Ziya , Kotecha Sita , Rajain Sakshi , Ravi Krish
Published: December 2021

Background

Gallbladder polyps are encountered in 5% of ultrasound scans and continue to remain a dilemma in terms of management. Very few polyps progress to cancer. However, most cancerous polyps are usually found at an advanced stage. It is therefore important to identify the premalignant polyps. There is a lack of national consensus in UK for surveillance of gallbladder polyps. Many trusts in the UK either adopt the European guidelines or formulate local protocols.  We aim to present our findings based on our local surveillance policy existent during the study period with a view to recommending new local guidelines.

Methods

A search from our radiology database being coded to gallbladder polyp identified patients. We identified 431 patients from 2017 – 2019 who had a total of 1014 scans. The data was collected from local hospital IT databases in terms of variables such as number of scans, polyp size, number of polyps, progression to surgery or discharge from surveillance and histology. The data was analysed on excel platform.

Results

Patient demographics revealed an incidence of 54% in females (males 46%) with an average age of 59.7 years. Pain was the dominant symptom prompting the first scan (48%). An average of 2.3 scans were performed per patient. 45% of the polyps were less than 5mm. Overall, 22% polyps demonstrated interval growth. Only 15% of polyps less than 5mm demonstrated interval growth and none required cholecystectomy.  6% patients proceeded to surgery mainly for symptoms (46%) compared to polyp progression (1.5%). No malignancy was identified in this study. 43% of patients with polyp diagnosis in primary care had no identified surveillance plan.

Conclusions

Our study demonstrates a low incidence of polyp progression. We would recommend stopping annual surveillance after 2 years from the index scan for multiple small (<5mm) polyps with little or no progression but continue with annual surveillance for polyps greater than 5mm. We would recommend reserving cholecystectomy for symptomatic polyps and polyps greater than 10mm. There is wide variation in surveillance practice particularly in primary care.  We would recommend sharing the guideline widely with primary care for optimal surveillance.
P-BN42 Percutaneous cholecystostomy - A practice review
Authors: Li Wing Ching , Elboraey Omar , Kilani Mohammad Saeed , Pursnani Kishore Gopaldas , Rajendran Ilayaraja
Published: December 2021

Background

Percutaneous cholecystostomy (PC) is performed occasionally in a highly selected group of patients with variable outcomes. The World Society of Emergency Surgery (WSES) updated guidelines(2020) has recommended PC as a treatment modality in patients admitted with ‘acute calculous cholecystitis’(ACC) with  who are not fit for surgery, including septic patients and those who show no improvement on conservative management within 48 hours. An audit was organised to review our patient selection for PC in the last 5 years in comparison to the latest WSES recommendations.

Methods

A retrospective observational study was conducted using a prospectively collected hospital database on patients who underwent PC between March 2016 and March 2021 in a teaching hospital. The patient cohort who underwent PC were compared and analysed against the set WSES guidelines.

Results

Some 23 patients were included. The median age was 82 years (range-61-90), with 13 females (56.5%) and 10 males (43.5%).19/23(82.6%) patients were at risk of sepsis on presentation, with two or more amber flag symptoms, whereas 4/23(17.4%) patients presented with confirmed sepsis. 19/23 (82.6%) were deemed unfit for surgery against 4/23 who were deemed fit based on the surgeons assessment. Patients unfit for surgery were treated with antibiotics following a diagnosis of ACC. The median time for patients to undergo PC from admission was 4 days. The 30-day mortality rate was 13 % (n = 3/23).

Conclusions

The study has demonstrated that our current practice for managing patients admitted with ACC and performing PC are mostly in line with the WSES guidelines. Considering individuals presentation and the surgeons clinical judgement into account, the practice was also likely impacted by COVID-19 the global pandemic. Further clinical studies may be required to determine specific patient groups who would benefit from PC.
P-BN52 Patient-reported outcome measures following fundoplication – lind and nissens - single centre, single surgeon results
Authors: Muthusami Anitha , Jayaprakash Sindoora , Jangan Akash , Sellahewa Chaminda , Akingboye Akinfemi
Published: December 2021

Background

Gastro-oesophageal reflux disease (GORD) affects approximately 10%-20% of adults in Western Countries. Surgery is indicated following failed medical therapy. This is recommended when GORD symptoms have a significant impact on the quality of life (QOL). A long term follow up is critical to authenticate outcomes following anti-reflux/hiatal hernia repair surgery. Objective information must be linked to the patient’s perception of the disease and the impact on the QOL. Our survey aims assess the long term patient’s satisfaction and the impact on QOL following standard Nissen’s and Lind’s fundoplication for GORD.

Methods

A single surgeon’s prospective database of laparoscopic and or open hiatus hernia repair and fundoplication with patient’s demographics since 2014 in a district general hospital was analyzed. These patients were contacted virtually between June and July 2021. Verbal consent was obtained,  the patients were asked to answer questions from the GERD HRQL (AUGIS modified for use in National Hiatal Surgery Registry) for Hiatus Hernia (HH) or Gastro-oesophageal reflux disease (GORD) or both to assess postoperative symptoms relief, complications, and overall quality of life. The scoring scale was divided into two categories; no symptoms or mild–moderate symptom improvement and those with significant symptoms.

Results

Of the 93 patients, 85 (91.4%) underwent primary laparoscopic repair with 91 cases performed as elective procedure. 68 patients (73%) underwent a Lind wrap, 24 (26%) had a floppy Nissen’s and one was a dor procedure. Three patients with unrelated death were excluded from the analysis. We had 67 responders (74.4%), 56 answered the GORD questionnaire and 66 responded to the HH questionnaire. 

84% patients with GORD and 85% of patients with HH had significant symptom improvement. 61 % and 55% suffered from significant gas bloat symptoms in each group. As for dysphagia; 77% had no - mild dysphagia and 23% had significant dysphagia and this was 79% and 21% in HH group. 

Conclusions

Overall patients satisfaction and improvement in quality of life was 90% . Half of our patient experienced gas bloat syndrome, which had little effect on their quality of life. 20% had long term dysphagia and one third of the patients seem to continue to use PPI despite expressing a satisfactory clinical improvement. It appears that patient’s long term improvement on  the   quality of life was satisfactory from both Nissen’s and Lind procedure.
P-BN55 Results of the ARROW survey of anti-reflux practice in the UK
Authors:   The ARROW collaboration
Published: December 2021

Background

Gastro-oesophageal reflux disease (GORD)  affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS).

We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of adherence to available guidelines.

Methods

Survey questions were iteratively developed by the ARROW steering committee and an online tool was developed to gather survey responses and contact details for the audit phase. The final questionnaire consisted of 90 fields per surgeon and 57 fields per institution. Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI surgical trainees. The online tool was piloted in three centres. The protocol for the study was peer reviewed and published in Diseases of The Esophagus in January 2021

Results

Survey responses were received from 151 surgeons at 57 institutions with a median of 40 cases annually and 4 surgeons/institution. Surgeons perform a median of 12(range 0-75) NHS cases and 6(range 0-75) private cases. 150/151 NHS surgeons perform some form of fundoplication for ARS, 4 surgeons perform LINX™, 4 STRETTA™ and 49 roux-en-y bypass for GORD.  Fundoplication procedures performed in the UK include Nissen (111/151), Watson (39/151), Toupet (72/151) and Dor (61/151). 104 surgeons adjust the wrap performed according to clinical symptoms, manometry or both. 20/57 centres had no access to a benign MDT to discuss ARS.

Conclusions

ARS in the UK lacks standardised approaches that can be reliably compared and therefore improved most surgeons perform less than 20 cases a year. Our survey revealed differences in which investigations are considered mandatory, which procedures are available to whom and with what variations, and available resources to facilitate shared decision making for patients with GORD and ARS surgeons. Our audit phase (begun in April 2021) will establish current practice, compliance with clinical guidelines and inform improvement projects and randomised trials in the future.