bluuebunny/crossref_metadata_2025 huggingface dataset:
P-BN59 Danger is there, do we want to know about it? Routine intra operative cholangiography highlights dangerous biliary anatomy for safer cholecystectomy
Authors: ain Noor Ul , Bibi Saira , Tait Ian , Zino Samer
Published: December 2021

Background

Normal biliary anatomy is uncommon. Different classification for biliary anatomy has been described, with Huang Types A4 & A5 of great interest for laparoscopic cholecystectomy (LC) due to the proximity of aberrant bile duct to Cystic duct (CD). These types of dangerous anatomy might contribute to bile duct injury. This study aims to analyse the prevalence of dangerous biliary anatomy.

Methods

Prospectively collected data for all patients who underwent laparoscopic cholecystectomy was analysed. All LC were performed by single surgeon or under  his direct supervision, between 01/07/2020 and 20/08/2021. Index admission and single session management of cholelithiasis disease with routine Laparoscopic cholecystectomy + intra operative cholangiography (IOC) +/- LCBD exploration were standard practice.

Results

Laparoscopic cholecystectomy was performed in 137 patients. Mean age was 56y (17-84).  62% were females.   66% of Laparoscopic cholecystectomies were emergency.

IOC was performed in 92% of cases. Abnormal biliary anatomy was found in 54% : Huang A1 - 48%, A2 - 29%, A3 - 12%, A4 - 9.7% and A5 - 0.7%.

Dangerous anatomy (A4 and A5) was found in 10.5%, 78 % were females.  Female with dangerous anatomy were younger than males 49 y, 60y respectively. Nassar difficulty grading for dangerous anatomy was as follows: G2 28%, G3 42% and G3 28%

Abnormal cholangiogram was found in 48%, due to filling defect in 58%, no contrast flow into duodenum in 4%, Cystic duct stone in 4%, and short CD in 8%. CBD stones were treated using transcystic approach in 92% of cases. No intra-operative or post operative complications were recorded for patients with dangerous anatomy. 

Conclusions

This study demonstrates that dangerous biliary anatomy, that could lead to bile duct injury is relatively common, occurring in 10.7% of LCs. Routine intra-operative cholangiography highlights these high-risk variations in biliary anatomy and may prevent inadvertent bile duct injury in such cases.
P-BN61 Optimal timing of laparoscopic cholecystectomy for admitted acute cholecystitis patients
Authors: Lucocq James , Scollay John , Patil Pradeep
Published: December 2021

Background

The Tokyo 2018 guidelines support emergency laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) over delayed laparoscopic cholecystectomy (DLC) for mild cholecystitis, substantiated by a lower total length of stay. The supporting studies are limited by small sample sizes, and clinically relevant findings may have been missed. The aims of the present paper were firstly, to compare the peri- and post-operative course following emergency and delayed LC for AC.

Methods

All patients who underwent ELC and DLC for AC following hospital admission between January 2015 and December 2019 were included in the study. Pre-operative, operative and post-operative data over a 100-day follow-up period were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were splint into groups based on previous admissions and outcomes were compared between ELC and DLC. Multivariate logistic regression models were then used on the entire cohort to adjust for other variables and to determine the impact of ELC versus DLC. Complications of the category Clavien-Dindo ≥2 were considered.

Results

In the group with no previous admissions (n = 630), DCL patients had lower rates of intra-/post-operative complications (8.0%vs.17.9%;p<0.001), lower rates of re-admission (6.6%vs.12.2%;p=0.04) and longer total length of stay (6dvs.5d;p=0.03). In patients with previous admissions (n = 181), DCL had lower rates of intra-/post-operative complications (14.1%vs.25.5%;p=0.06) but there was no significant difference in length of stay (13dvs.12d;p=0.81). The ELC group had a significantly lower admission CRP, ASA and age (p < 0.001). In the multivariate logistic regression models, ELC was positively associated with subtotal/conversion to open (OR,1.94;p=0.01), drain insertion (OR,2.54;p<0.001), bile leak (OR,2.38;p<0.001), post-operative imaging (OR,1.83;p=0.01), longer post-operative stay (OR,7.26,p<0.001) and readmission (OR-1.9;p=0.01). 

Conclusions

DLC, once the period of active inflammation has settled, offers superior post-operative outcomes, including lower rates of complication, re-admission and post-operative length of stay; however is associated with longer total length of stay. DLC is only advised where the risk of re-admission is minimised (i.e surgery six weeks following the episode) and relies on the management of surgical waiting lists.
P-EGS02 Impact of delayed elective laparoscopic cholecystectomy on incidence and complications from gallstone ileus
Authors: Talib Mazuin , Loh Zhi Yu , Malek Hidayatul Abdul , Sharma Vivekananda , Kanakala Venkat
Published: December 2021

Background

The negative impact of the COVID-19 pandemic on the provision of elective surgery in the UK has been profound. Per the latest National figures, a total of 4.59 million patients are awaiting an elective operation (1). In our Trust, emergency operations and cancer service took precedence as we worked to minimize risks of COVID-19 while providing life-saving procedures. Subsequently, our ‘hot gallbladder’ operating list was put on hold for a period of 18 months. In our Trust, the current waiting time for an elective laparoscopic cholecystectomy is 52 weeks for symptomatic gallstone disease. Gallstone ileus is a well-recognized but rare complication of gallstones (2) and needs operative treatment. We performed this study to investigate the impact of delayed cholecystectomy on the incidence of gallstone ileus and the morbidity and mortality associated with this.

Methods

Retrospective study reviewing all acute admissions with gallstone ileus for 4 years from 2016 to 2020. Total number of patients was 19. Data collated from patient’s notes to include demographics and co-morbidities, operative notes, theatre records, and WebICE.

Results

Demographically, there was significant female preponderance (M : F : 1 : 18). Mean age of patients was 76.7 years. 17/19 patients underwent laparotomy as the primary operation (89%) and 1 (5%) had a laparoscopic procedure. 1 patient (5%) was managed conservatively. All patients had a CT scan as pre-operative imaging. 7 (34%) also had USS and 4 (20%) had MRCP. Mean length of stay in hospital was 13 days. 3 (15%) patients required re-admission to hospital for surgical and medical complications within 30 days. 3 (15%) patients returned to theatre for a second laparotomy within the index admission for recurrence of gallstone ileus. 8 (40%) patients had post-operative complications. There were 2 (10%) mortalities. 9 (45%) patients had gallstone related complications preceding their index presentation; majority (66%) which was calculous cholecystitis. The mean time between diagnosis of gallstone disease and emergency laparotomy for gallstone ileus was 38 months.

Conclusions

Gallstone ileus can be a life-threatening complication of gallstone disease and needs prompt recognition and treatment. Patients with known gallstones with symptoms of bowel obstruction should have a CT scan at time of presentation. Surgery is the mainstay treatment following resuscitation and concurrent conservative management. Early elective laparoscopic cholecystectomy can prevent mortality and morbidity from emergency laparotomy for gallstone ileus.
P-EGS07 Two years of Acute Biliary Admissions at a tertiary care centre over the Covid-19 pandemic: a closed loop audit with implementation of an acute referral system
Authors: Refalo Andrew , White Annabelle , Widlund Hedda , Ebied Husam
Published: December 2021

Background

AUGIS recommends patients diagnosed with acute cholecystitis and gallstone pancreatitis to receive a laparoscopy cholecystectomy on the index admission, ideally within 72 hours of presentation. Early laparoscopic cholecystectomy is associated with better patient outcomes and reduced readmission rates. During the Covid-19 pandemic emergency surgery, if possible was avoided. These patients are referred for an elective cholecystectomy, however waiting times can be lengthy with readmissions common prior to surgery. 

Methods

We performed a closed loop audit on acute biliary admissions to a central London tertiary care centre. We assessed waiting times to laparoscopic cholecystectomy for patients fit for surgery as well as readmissions prior to surgery. The data was collated over a one-year period (01/03/2019 to 29/02/2020), analysed and presented to the senior biliary surgery team. A dedicated e-referral system for patients who did not receive a laparoscopic cholecystectomy on index admission was implemented. Post intervention admissions were re-audited over a second year (01/03/2020- 30/01/2021) and re-analysed to assess the effect of the intervention.  

Results

A total of 111 patients with acute cholecystitis, 52 with gallstone pancreatitis, 34 with biliary colic, 36 with choledocholithiasis and 10 with ascending cholangitis, were included. Prior to implementation of our referral system average waiting time to laparoscopic cholecystectomy was 98.2 weeks, reduced to 47.7 weeks post referral system implementation. Reduction in waiting times resulted in readmission rates reduced by: 23.3% in Choledocholithiasis; 17.4% in Biliary Colic;   16.7% in Ascending Cholangitis; 12.8% in Acute Cholecystitis and 8.3% in Gallstone pancreatitis. 

Conclusions

Admissions with acute biliary colic compose a substantial workload. The COVID-19 pandemic has resulted in a preference for elective versus emergency laparoscopic cholecystectomy. However, delay in surgery results in a readmission burden on emergency surgery departments and worse patient outcomes hence laparoscopic cholecystectomy should be performed as soon as possible following initial admission. This audit demonstrates that a dedicated biliary referral system reduced waiting time which translates to a reduction in admission rates. The importance of this referral system is magnified in the recovery phase of the pandemic where we continue to recover waiting times.
P-EGS15 Gastric pneumatosis in an elderly patient with recurrence of gastric volvulus
Authors: Ledda Virginia , Satchidanand Rajesh Yagati
Published: December 2021

Background

Gastric pneumatosis (GP), defined as the presence of air in the gastric wall, is a rare CT finding. It is associated with a spectrum of conditions which can range from benign and self-limiting to severe with high mortality rate. A gastric volvulus occurs with a rotation of 180 degrees or more of the stomach around its longitudinal or transverse axis. It is a rare event, and can culminate in obstruction, strangulation, ischaemia and necrosis. We present a case of gastric pneumatosis in a patient suffering with hiatus hernia and a history of recurrent gastric volvuli.

Methods

An 83-year-old man presented with a history of vomiting and abdominal pain. His background included a known hiatus hernia with previous episodes of gastric volvulus. A computer tomography (CT) showed a gastric volvulus with air in the gastric wall, in the intrahepatic biliary tree and porta hepatis. Conservative management was pursued with IV PPI and antibiotics, keeping the patient nil by mouth. He improved clinically and a repeat CT scan showed regression of the gastric pneumatosis, with resorption of gas in the porta hepatis and regression of the pneumobilia. He was discharged home 12 days after his initial presentation.

Results

Gastric pneumatosis (GP) is described as a rare finding that can occur in conditions such as gastric emphysema (GE) and emphysematous gastritis (EG). GE is described as a more benign condition, usually self-limiting which can be managed conservatively in most cases and rarely requires surgical interventions. EG is a more severe condition with a high mortality rate, and more aggressive treatment is advocated. The diagnostic process can be challenging but literature shows lactate, the presence of metabolic acidosis and peritonitis can help differentiating between the two clinical entities and choosing the appropriate management plan.

Conclusions

This case described a patient presenting with a gastric volvulus with the presence of gastric pneumatosis, pneumobilia and portal venous gas. These findings were diagnosed as gastric ischaemia secondary to volvulus. In this case the patient made a good recovery after being managed conservatively. GP is a rare CT entity which can be found in the presence of GE or EG. Differentiating between the two can be a challenging process, aided by clinical examination as well as blood test results. Achieving the right diagnosis is key as radical surgical intervention is not always needed to guarantee a good outcome.
P-EUS02 The value of Endoscopic Ultrasound (EUS) in the investigative pathway of Acute Idiopathic Pancreatitis (AIP)
Authors: Bhatti Sumbal , Evans Laith , Kumar Bhaskar
Published: December 2021

Background

The British Society of Gastroenterology (BSG) guidelines on the management of acute idiopathic pancreatitis (AIP) state the incidence of idiopathic cases to be no more than 30%. However, before a firm diagnosis of AIP is made, Endoscopic Ultrasound (EUS) may be used to determine occult causes. This approach may help prevent recurrent attacks which may evolve into chronic pancreatitis.

Methods

Retrospective analysis over a one-year period of cases of AIP in a tertiary referral center was performed to see the incidence of AIP and the role of EUS. Patients with an identifiable cause for pancreatitis were excluded, leaving only those who had received a diagnosis of AIP and the diagnostic value of EUS was examined.

Results

Of the 101 patients diagnosed with AIP, 19% (n = 19) underwent an EUS succesfully. 79% (n = 15) had no underlying cause of pancreatitis identified on EUS. In the remaining 21% of cases (n = 4), microlithiasis, ductal stones, and pus requiring drainage were common findings. Of these patents, only 1 was referred for surgery. In the patient group with negative findings on EUS, 4% were unaffected, 2% were refered for surgery, 2% died and 7% had recurrent episodes of pancreatitis.

Conclusions

The results of this study show that EUS is a valuable modality in patients with suspected AIP, with a positive diagnostic rate of 21%. Therefore, we propose EUS needs to be included in the investigative pathway of all suspected AIP. Although EUS is a relatively scarce resource, further research is required to establish guidelines for the investigation of suspected AIP.
P-L02 Machine learning to evaluate liver reserve function based on venous blood biochemistry
Authors: Wang Zhengfeng , long shi zhi , zheng jnxing , rui shaozhen , zhang hui , li xun , zhou wence
Published: December 2021

Background

The accurate and comprehensive evaluation of liver reserve function is crucial for daily follow-up and medical treatment of patients with liver disease. However, existing techniques are too complex and costly for universal implementation.To develop a convenient, reliable method to evaluate liver reserve function based on eight biochemical indicators measured from venous blood. 

Methods

Blood test results (albumin (Alb), total bilirubin (TBIL), prothrombin time (PT), international normalized ratio (INR), total cholesterol (TC), cholinesterase (ChE), aspartate amino transferase (AST), and alanine transaminase (ALT)) were collected retrospectively from 660 patients treated at the first hospital of Ianzhou University from 2016 to 2018. As the reference standard for liver reserve function, indocyanine green (ICG) clearance test results were also collected from the same patients at the same times. The patient data were processed and analyzed to construct a machine learning model, eXtreme Gradient Boosting (XGBoost), and a generalized linear model (GLM) to predict liver reserve function based on the eight biochemical indicators.

Results

Results showed that the predicted XGBoost values were closely correlated with the actual ICG 15-minute retention rates (R = 0.969, R2 = 0.939), while the GLM values had a relatively low correlation (R = 0.566, R2 = 0.320). These findings indicate that the developed model can be used to evaluate liver reserve function with comparable performance to the ICG clearance test. Furthermore, the XGBoost model exhibited superior prediction compared with the GLM. Hence, the XGBoost model developed using machine learning can be utilized to evaluate liver reserve function from eight biochemical indicators that are closely related to liver function, commonly used clinically, and easier to obtain than ICG clearance measures.

Conclusions

The results predicted by the XGBoost model were highly accurate when compared with the results of the actual ICG test, demonstrating the strong practical clinical value of the model.
P-L08 Novel surgical technique for the management of biliary-enteric anastomotic strictures
Authors: Al-Munaizel Tariq Tariq , Jarad Obada Abu
Published: December 2021

Background

This study presents an invented surgical technique for dealing with biliary-enteric anastomotic strictures with the potential to replace currently used methods in certain cases.

Methods

In this retrospective study, a novel surgical technique was introduced in the management of eight patients with bilioenteric strictures between January 2016 and May 2018.

Results

Our new technique was associated with a 100% success rate where patency of anastomosis was achieved in all patients along the 28 month follow-up period. Only two of the patients developed a complication including wound-site infection, and cholangitis at the 17th month follow-up. None of the patients developed intrahepatic biliary dilation or stricture recurrence.

Conclusions

This novel surgical approach may reduce recurrent medical and radiological interventions and the need for anastomosis revision. It may also lessen the rate of complications. However, larger scale studies are needed to confirm such findings.
P-L10 Individualized Enhanced recovery after surgery improves postoperative outcomes in hepatocellular carcinoma patients
Authors: Zhang Yu , Zhang Lei , Xu Zhongling , Feng Zihan , Chen Yinze , Chen Zhong
Published: December 2021

Background

Hepatocellular carcinoma (HCC) patients often undergo curative liver resection to treat this form of cancer. Hepatectomy is, however, a form of major surgery associated with many significant risks including prolonged hospitalization, high costs, impaired physiological function, and high postoperative complication rates. Enhanced recovery after surgery (ERAS) is a multidisciplinary approach that seeks to expedite postoperative recovery in patients undergoing major surgeries in order to lower postoperative complication rates. This study was thus designed to assess the efficacy and safety of individualized ERAS approaches in patients undergoing hepatectomy. 

Methods

In total, we retrospectively analyzed data from 90 HCC patients that underwent hepatectomy between October 2018 and August 2019. All patients met the study enrollment criteria and provided written informed consent to participate. All studies were approved by the Hospital Research Ethics Committee and were consistent with the Declaration of Helsinki. Patients were randomly divided into two groups (n = 45 each) based on the employed perioperative treatment strategies: a conventional treatment group and an ERAS treatment group. Key outcomes were then compared between groups, including postoperative pain scores, duration of postoperative hospitalization, medical costs, and rates of readmission. 

Results

ERAS treatment was associated with lower postoperative pain scores at 24, 48, and 72 h post-treatment (P < 0.05), with a shorter postoperative hospitalization duration (8.16 days vs.10.49 days; P < 0.004), and with lower medical costs (P < 0.004) as compared to traditional treatment. No significant differences in complication rates (P > 0.05) or readmission rates (P > 0.557) were observed between these groups. 

Conclusions

Individualized ERAS improves patient postoperative recovery more effectively than traditional treatment in patients undergoing hepatectomy.
P-L14 Ex-vivo normothermic perfusion of an abattoir-derived porcine hepatic segment as a model for scientific research
Authors: Kanani Trisha , ElSamani Kareem , Chung Wen , Cox Michael , Sahloul Mohamed , Isherwood John , Oggioni Marco , Garcea Giuseppe , Dennison Ashley
Published: December 2021

Background

The human immune response to bacterial and viral pathogens has been the focus of intense research, but details on the earliest phases of infection remain unclear. Better knowledge regarding the response of immune cells in the liver is important for the treatment of severe bacterial disease. Ex vivo perfusion which mimics physiological conditions of the liver may provide useful models for this research.  An ex vivo model which perfuses hepatic segments would allow translational research on a physiological and reliable model in the scarce resource of human organs. Here we describe the extra-corporeal perfusion of a porcine hepatic segment.

Methods

Whole porcine livers were retrieved from animals slaughtered according to UK laws for food production and connected to a normothermic extracorporeal perfusion circuit. Constant perfusion via the hepatic artery and portal vein with heparinized autologous blood was established. Sodium bicarbonate, epoprostanol sodium and calcium chloride were also added to the perfusate to regulate acid-base status and reduce vasospasm. Functionality was assessed by monitoring blood-gases, perfusion pressures and flow rate. A segmental ex-vivo liver resection was performed to leave hepatic segment IV in circuit and isolated segment IV perfusion was maintained for one hour.

Results

Portal venous pressure was maintained between 8-16mmHg and hepatic arterial pressure between 80-90mmHg. Metabolic acidosis resolved with addition of sodium bicarbonate to the circuit with a pH of 7.42 after segmental perfusion for 1 hour. The lactate increased over the course of the perfusion to 20mmol/L after 1 hour of perfusion, however glucose levels were found to improve with the addition of sodium bicarbonate to the circuit.  

Conclusions

Isolated segmental perfusion via ex-vivo resection of porcine hepatic segments is technically challenging. Ischaemic-reperfusion injury coupled with progressive metabolic acidosis may limit model viability. However, addition of sodium bicarbonate to the perfusate aids reduction of glucose levels and improves acidosis. Successful perfusion of a porcine hepatic segment provides the potential for segmental perfusion of human hepatic segments such as those resected during hemi-hepatectomies (HRA approved; REC 21/PR/0287). This is an important milestone leading to the creation of a model to study the early changes in human liver tissue for example during infection.
P-O01 A patient education video to support the management of post-gastrectomy / oesophagectomy syndromes
Authors: Roberts Geoffrey , Stone Andrew , Sunderland Nicola , Grimes Sam , Reimann Frank , Gribble Fiona , Hardwick Richard
Published: December 2021

Background

Oesophagectomy and gastrectomy result in profound and life-long changes in eating behaviour and appetite, and significant post-prandial symptoms. Despite decades of research, and recent advantages in the understanding of gut physiology, medical approaches to post-resectional patient care remain limited. The mainstay of treatment is patient education. Using clinical and lab-based studies, we investigated the effects of altered gut hormone secretion in patients after surgery for oesophageal and gastric cancer. We then produced a partially animated patient information video to better equip our patients to manage their altered alimentation.

Methods

The scientific background to the video was previously presented at AUGIS, and published. Studies included examination of eating behaviour, post-prandial symptoms, glucose homeostasis, gut hormone profiles and intestinal transcriptomic / peptidomic changes in a cohort of patients after oesophagectomy and gastrectomy. The movie storyboard and script were written by a team of surgeons, dietitians, patient representatives, clinical scientists and communications specialists. The goal was to communicate the physiological basis of altered eating in post-operative patients and appropriate nutritional strategies.

Results

The video is now freely available on Vimeo at: https://vimeo.com/356892336

It is in routine use for pre- and post-operative patient education.

Conclusions

Multimedia patient education is a useful tool to help manage the late effects of upper GI cancer treatment.
P-O07 Endoscopic submucosal dissection for giant esophageal lipomatous tumors
Authors: Geng Zi-Han , Xu Xiao-Yue , Zhu Yan Yan , Su Wei , Li Quan-Lin , Zhou Ping-Hong
Published: December 2021

Background

Thoracotomy is the foremost choice of giant esophageal lipomatous tumors in previous studies, but it is highly traumatic and possibly diminishes the quality of patients’ life. To minimize such impacts, a minimally invasive method without loss of curability is desirable for giant lipomatous tumors of the esophagus. With recent progress in endoscopic techniques and devices, endoscopic submucosal dissection (ESD) has been successfully used to remove esophageal or gastric submucosal tumors (SMTs).

Methods

Objective: To evaluate the clinical impact of ESD for giant esophageal lipomatous tumors. 

Design: Single-center, retrospective study.

Setting: Academic medical center.

Patients: Six patients with six giant lipomatous tumors of the esophagus between February 2013 and December 2020.

Interventions: ESD.

Main Outcome Measurements: Procedure duration, en bloc resection rate, complications, local recurrence, and distant metastases.

Results

Endoscopic en bloc resections of esophageal lipomatous tumors were successfully performed in all patients, with a mean duration of 56.5 ± 26.0 min. All en bloc resection lesions showed both lateral and deep tumor-free margins. The average maximum diameter of the esophageal lipomatous tumors was 171.7 ± 66.2 mm. No complications such as bleeding and perforations happened during hospitalization with 4.0 ± 1.6 days. Besides, local recurrence and distant metastasis have not occurred during the follow-up period.

Conclusions

ESD was a safe and effective way to dissect giant lipomatous tumors of the esophagus thoroughly.
P-OGC03 Pancreatic enzyme supplementation improves quality of life in patients following surgery for upper GI cancer
Authors: Kay Robert , Alexander Callum , Rahman Sajid Waheed , Deans Chris
Published: December 2021

Background

Unpleasant abdominal symptoms are common following surgery for upper gastrointestinal (UGI) cancer and may occur secondary to pancreatic exocrine insufficiency (EPI). This study investigated symptoms of EPI in patients following surgery and assessed the effect of pancreatic enzyme supplementation (PERT) on these symptoms and the effect of supplementation on quality of life.

Methods

Patients were assessed for symptoms of EPI using a novel questionnaire. Patients who reported two or more symptoms suggestive of EPI were prescribed PERT. Abdominal symptoms were reassessed following treatment. Quality of life (QoL) was studied using the SF-36 questionnaire before and after treatment. Faecal elastase was also measured in a patient subgroup.

Results

Fifty-six out of 57 patients (98%) reported at least two symptoms of EPI. Following PERT every patient reported fewer abdominal symptoms; median 5 symptoms before treatment reduced to two symptoms following treatment (p < 0.0001; Wilcoxon rank). Reduced faecal elastase concentration was associated with more frequent abdominal symptoms; median 5 symptoms versus 3 symptoms (p = 0.043; Mann Whitney U test). PERT increased quality of life scores for every patient in each of the 5 principle health domains.

Conclusions

Symptoms of EPI are common among patients following UGI cancer surgery. PERT reduces unpleasant abdominal symptoms and this leads to significant improvements in quality of life across global health domains. PERT should be offered to all post-operative UGI cancer patients with symptoms suggestive of EPI.
P-OGC19 The predictive role of cardiopulmonary exercise testing in gastric cancer surgery
Authors: Chmelo Jakub , Prasad Pooja , Brown Joshua , Navidi Maziar , Phillips Alexander W
Published: December 2021

Background

The role of Cardiopulmonary Exercise Testing (CPET) prior to major surgery has been an area of growing interest over the last two decades. CPET offers an objective and composite measure of physiological functional reserve, and thus can be used to identify patients at highest risk of peri-operative morbidity and mortality. Although the role of CPET has been investigated with respect to outcomes after oesophagectomy, no clear data exist into the predictive role of CPET specifically relating to gastric cancer surgery. The aim of this study was to identify CPET parameters predictive of adverse outcome in patients undergoing curative gastric resections.

Methods

Patients who underwent CPET followed by curative total or subtotal gastrectomy for gastric or junctional adenocarcinoma between January 2013 and December 2019 in a single high-volume centre were included in retrospective analysis. CPET variables were categorised as per cut-off values from other surgical populations (AT < 11ml.min-1.kg-1, VO2peak<15ml.min-1.kg-1, VE/VCO2 at AT > 34). Associations between these variables and postoperative outcomes were analysed using chi squared or Fisher’s exact test.

Results

There were 252 patients included in the study. Patients with VE/VCO2>34 were more likely to return to the intensive care unit (ICU) (p = 0.033) and had a higher chance of in-hospital mortality (p = 0.012). AT < 11ml.min-1.kg-1 or VO2peak<15ml.min-1.kg-1 were not associated either with return to ICU (p = 0.243, p = 0.202) or with in-hospital mortality (p = 1.000, p = 1.000).

Conclusions

Although much has been published on the importance of CPET assessment prior to major abdominal surgery, there is a paucity of literature specifically looking at its role in patients with gastric cancer. Patients with ventilatory inefficiency (VE/VCO2>34) are more likely to return to ICU or to die during hospital stay after total/subtotal gastrectomy for malignant disease. This information should play a more prominent role when assessing patients’ fitness prior to surgery.
P-OGC30 High volume oesophagogastric resection in a small private hospital during COVID 19, April 2020- April 2021
Authors: Knight William , Theophilidou Elena , Hossain Tanvir , Hatt Jake , Yanni Fady , Zanotti Daniela , Catton James , Welch Neil , Vohra Ravi , Parsons Simon
Published: December 2021

Background

Like other hospitals at the peak of the pandemic, our institution had limited elective critical care capacity. This study summarises the outcomes of patients undergoing oesophagogastric (OG) resection at our institution, treated as the result of the emergency national contract between the NHS and the independent sector hospitals.

Methods

Patients undergoing OG resection at our institution between April 2020 and April 2021 were included. Patients were managed through the multidisciplinary team and were treated according to standard ERAS pathways, involving critical care input. National OG Cancer Audit (NOGCA) metrics were collected and compared to pre-COVID data.  

Results

81 patients underwent oesophagogastric resection in the private sector (60 oesophagectomies). Median length of stay was 9 days (9 pre-COVID). This included 21 patients who were repatriated to our main centre for ongoing management. 30-day mortality was 3.7% (1.8% pre-COVID), 90-day mortality 6.7% (4.2% pre-COVID). This included one patient who contracted COVID following discharge. 9 patients suffered an anastomotic leak, equating to a leak rate of 11% (7% pre-COVID). 22 resections were performed at our main centre (110-140 OG resection pre-COVID)

Conclusions

It is likely the private institution in this study represented one of the busiest oesophagogastric centres in the UK during COVID-19. A large cohort of patients underwent potentially curative surgery as a result of the emergency contract, who would have otherwise been placed on prolonged or palliative chemotherapy. 30 and 90-day mortality and anastomotic leak rates were higher than pre-pandemic levels, reinforcing the value of centralised tertiary OG resection services.
P-OGC31 Robotic Upper GI Surgery: Is it Feasible, Safe and Can it Improve Patient Outcomes?
Authors: Chaudhury Madhu , Johnson Judith , Pursnani Kishore , Turner Paul
Published: December 2021

Background

Robotic surgery has been increasingly applied in different specialties. The Rosemere Cancer Foundation funded the Da Vinci robot for Upper GI services at our tertiary Upper GI Cancer Centre which serves a population of approximately 1.5 million people. In 2017, two of our UGI surgeons performed the first robotic GIST excision in the UK successfully. The patient was discharged 5 days later after an uneventful recovery. We have subsequently performed increasingly complex benign and malignant Robotic UGI procedures. Our primary and secondary aims looked at the length of stay (LOS) in critical care and the complete hospital admission. 

Methods

Two UGI Consultants observed cases in established centres in Netherlands and Germany. Following this, they undertook 60 hours of simulation practice, online modular training and 3 sessions of wet lab training. Their initial 10 resections were completed under proctorship. A database was designed collecting information from the notes, November 2017 till July 2021 prospectively. This database was compared against a retrospective database on the same outcomes for non robotic cases over the same time period, performed by the same surgeons. LOS was statistically assessed using Mann-Whitney U test.

Results

As of July 2021, we have completed 73 cases. These are 25 benign and 48 cancer cases. The M:F was 1.5:1 and the median age was 66 years (22-84 years). The primary and secondary outcomes are illustrated below. 

Conclusions

Robotic Upper GI surgery is safe and feasible with good short term outcomes. There is a reasonable learning curve and therefore a structured learning programme is needed before embarking. The main advantage from preliminary data suggests a reduction in the LOS in critical care. The cost-effectiveness in complex benign surgeries remains to be determined with increase volume of cases.

P-OGC31 Figure 1
P-OGC38 The Impact of the COVID-19 Pandemic on Barrett’s Oesophagus and Oesophago-gastric Cancer
Authors: Turkington Richard C , Lavery Anita , Donnelly David , Gavin Anna T , McManus Damian T , Cairnduff Victoria , McShane Charlene M , Johnston Brian T , Anderson Lesley A , Coleman Helen G
Published: December 2021

Background

The COVID-19 pandemic has placed an inexorable strain on endoscopy services worldwide, affecting the diagnosis of oesophago-gastric (OG) cancer and Barrett’s oesophagus (BO). As coronavirus infection rates rose many professional bodies advised that all endoscopy, except emergency and essential procedures be stopped immediately. We sought to quantify the decline in OG cancer and BO diagnoses following implementation of British Society of Gastroenterology (BSG) guidance related to COVID-19 and the psychosocial effects on BO patients.

Methods

We examined OG cancer and BO diagnoses in Northern Ireland from March-September 2020 and compared them with the three-year average number of patients  during the same time period (corresponding to weeks 10-37) between 2017-2019 by utilising Northern Ireland Cancer Registry (NICR) data. The psychosocial impact of COVID-19 was assessed using an online survey, which included validated WHOQOL-BREF and EQ-5D-5L quality of life measures, and was completed by 24 BO patients from April-May 2020.

Results

Between March and September 2020 in Northern Ireland, the proportion of OG cancer and BO diagnoses declined by 26.6% and 59.3%, respectively, compared to expected levels. In April, BO diagnoses fell by 95.5% but by September, whilst OG cancer rates had returned to baseline, BO cases remained supressed by approximately 20%. We estimate that these declines in diagnosis represent 53 ‘missed’ OG cancer and 236 ‘missed’ BO diagnoses. In the online survey sample, BO patients reported consistently lower quality of life scores than population norms, and highlighted a number of concerns with regard to their health and care.

Conclusions

The COVID-19 pandemic has resulted in an abrupt decline in OG cancer and BO diagnoses and has profoundly impacted the wellbeing of BO patients. Our study represents the first report of the impact of COVID-19 on the diagnosis of BO.  Strategies to mitigate the ongoing effects of the pandemic are urgently required to preserve the ability to rapidly detect and diagnose cancer and pre-malignant conditions.
P-OGC43 Morbidity and unplanned hospital attendance among patients with oesophagogastric cancer treated with home enteral nutrition
Authors: Olusona Okiki , Brett Orla , White Cathy , Hickey Wendy , Coleman Claire , Elliott Jessie A , Arumugasamy Mayilone , Robb William B
Published: December 2021

Background

Nutritional optimisation is an essential component of prehabilitation and enhanced recovery for patients with oesophageal and gastric cancer, but may be associated with increased burden of inpatient care. The aim of this study was to determine risk factors associated with complications and unplanned hospital attendance among patients treated with home enteral nutrition.

Methods

Consecutive patients with oesophageal or gastric cancer commencing home enteral nutrition from March 2020-June 2021 were prospectively studied. The primary outcome measure was the incidence of complications associated with home enteral feeding requiring unplanned hospital attendance. Univariable and multivariable linear and logistic regression were used to determine factors independently associated with enteral feeding associated morbidity and healthcare utilisation.

Results

70 patients were studied (27% pre neoadjuvant therapy, 63% postoperative; 19% gastrostomy, 81% jejunostomy). Tube complications requiring unplanned hospital attendance occurred in 33% of patients (25% gastrostomy, 38% jejunostomy, P = 0.405), most commonly dislodgement (15%), fixation problem (13%), and blockage (6%). Small bowel obstruction was rare (1.4%). Inpatient length of stay (LOS) following feeding tube placement and training was 5.1±2.4 days (gastrostomy: 5.5±2.7, jejunostomy: 4.4±1.9 days, P = 0.074). 17 unplanned hospital visits among nine patients (13.0%) occurred with a cumulative LOS of 71 inpatient days. On multivariable analysis patients undergoing neoadjuvant therapy were at the greatest risk of overall enteral feeding tube morbidity (OR19.34 [3.29–113.56], P = 0.001), dislodgement (OR19.09 [2.35-155.11], P = 0.006) and unplanned hospital attendance (P < 0.001). Older patients were at increased risk of tube dislodgement (OR1.14 [1.02–1.28], P=0.024) and unplanned hospital attendance (P = 0.034).

Conclusions

Unplanned hospital attendance is common among patients undergoing supplemental home enteral nutrition during treatment for oesophagogastric cancer. Fixation problems and dislodgement account for the majority of presentations, and are more common among older patients and those undergoing neoadjuvant therapy. Pragmatic strategies to optimise tube fixation and minimise the need for unplanned hospital visits among patients receiving home enteral nutrition are urgently needed.
P-OGC59 Pattern of recurrence following neoadjuvant treatment and two-stage oesophagectomy for oesophageal/junctional adenocarcinoma: 10-year results from a high-volume centre
Authors: Brown Joshua , Calabrese Michele , Chmelo Jakub , Prasad Pooja , Phillips Alexander
Published: December 2021

Background

Disease recurrence remains high following oesophagectomy for oesophageal and junctional adenocarcinoma in spite of the incremental gains from improved neoadjuvant treatment (NAT). Follow-up remains important for the detection and treatment of recurrence, although the optimum surveillance strategy remains undefined. Recurrence after treatment can occur locoregionally, distantly, or a combination of both. This retrospective review of a single, high-volume centre’s 10-year experience has sought to determine the pattern of recurrence in those who have received curative NAT followed by two-stage subtotal oesophagectomy (2S-STO) for oesophageal and junctional adenocarcinoma.

Methods

A retrospective analysis was performed on a cohort of patients from a high-volume, single centre between January 2009 and January 2019 who had confirmed disease recurrence after receiving NAT and 2S-STO for either oesophageal or junctional (Siewert I/II) adenocarcinoma. The Unit’s prospectively collected cancer database was utilised as well as patients’ notes to determine the pattern of recurrence seen in this cohort. Patients receiving a three-stage or transhiatal oesophagectomy for any cause, or those diagnosed with squamous cell carcinoma were excluded.

Results

215 patients were identified with recurrence following NAT and 2S-STO for oesophageal/junctional adenocarcinoma within the 10-year period. The median age was 69 (range 23-85) with 67% being male and 33% female. The median time to diagnosis of recurrence was 13 months following surgery. 87 (40%) patients were diagnosed with locoregional recurrence, with the commonest pattern being in mediastinal or abdominal lymph nodes, followed by peritoneal disease. 62 (29%) patients were diagnosed with distant recurrence, with the vast majority being in the liver or lungs. 66 (31%) patients had evidence of both locoregional and distant spread at diagnosis of recurrence.

Conclusions

The incidence of recurrence following curative treatment for oesophageal and junctional adenocarcinoma remains high. Locoregional disease appears to be the commonest pattern of recurrence as identified in this study, which would confirm spread predominates via the lymphatic and transcoelomic routes. Liver and lung remain the commonest sites for haematogenous spread, although other sites include adrenal, brain and bone. Although the optimum follow-up strategy remains undefined in such patients, timely investigation of symptoms is required for early diagnosis so as to optimise the benefits of palliative treatment.
P-OGC67 Gastric GISTs: Can presentation, Location and Radiological Features predict behaviour? – Experience in a UK cohort
Authors: Gerretsen Hannah , George Gincy , Russell Beth , Gossage James , Kelly Mark , Davies Andrew , Baker Cara
Published: December 2021

Background

Gastrointestinal stromal tumours (GISTs) most commonly arise in the stomach, vary significantly in behaviour and can be difficult to risk stratify accurately pre-operatively. They are increasingly being identified incidentally during endoscopies or cross-sectional imaging. They have malignant potential and but vary from very low to high-risk. Pre-operatively, histological diagnosis can be achieved by performing endoscopic ultrasound (EUS) guided fine-needle aspirate or biopsy, but samples often contain insufficient material. This study aims to assess other features help identify aggressiveness of GISTs pre-operatively to help guide management decisions.

Methods

This is a retrospective cohort study analysing patients treated surgically for GIST from 2011-2020 at a UK tertiary centre. Exclusion criteria were non-gastric GISTs and patients who received a different diagnosis post-operatively. Hospital electronic patient record and e-noting systems were used to collect data. Risk groups were stratified according to the NCCN risk classification for GIST. ‘Very low risk’ and ‘low risk’ groups were combined in the analysis to form the ‘lower risk’ group; ‘moderate risk’ and ‘high risk’ categories combined to form the ‘higher risk’ group. Statistical analyses were conducted using STATA version 15.

Results

171 patients were included in total. OGD diagnosed gist on histology if ulcerated in 14.7% of cases. EUS biopsy was performed in 39% of cases pre-operatively – 84.6% of these were diagnostic. There was a higher proportion of higher risk GISTs in the GOJ/cardia region than lower risk GISTs (16.2% versus 6.7%), though this did not reach statistically significance (p = 0.32). A greater proportion of higher risk tumours were irregular in outline (p=.26),  heterogenous (p = 0.003) and necrotic (p = 0.001) than lower risk tumours. In addition, higher risk tumours were significantly more likely to be exophytic than lower risk tumours, which were significantly more endophytic (p = 0.05). A ROC curve including all the variables had an AUC of 0.8971.

Conclusions

This is the largest analysis of gastric GISTs in a UK population. This study found that a higher proportion of higher risk tumours were irregular, heterogenous and necrotic than lower risk tumours. In this study, a greater proportion of higher risk tumours arose in the GOJ/cardia. In keeping with muscularis origin, endoscopic biopsy was found to be a poor diagnostic tool unless ulcerated. EUS and FNA biopsies had a much higher rate of histological confirmation. This knowledge might help facilitate a more individualised approach with non-operative surveillance in lower risk tumours or expedited surgery in higher risk lesions.
P-OGC97 Development and piloting of surgical quality assurance methods for randomised controlled trials (RCTs): an example from a trial comparing laparoscopically assisted oesophagectomy vs. open oesophagectomy
Authors: Blazeby Jane , Blencowe Natalie , Skilton Anni , Shirkey Beverly , Ward Liz
Published: December 2021

Background

RCTs in surgery are frequently criticised because the standard to which operations are performed (quality assurance - QA) is not considered during study design and delivery, risking performance bias. Lack of clarity about surgical QA may also influence the successful implementation of RCT results into routine practice, because it is unclear how procedures were undertaken. We developed QA measures for an RCT comparing laparoscopically assisted and open oesophagectomy (LAO and OO).

Methods

Five QA categories were developed during the pilot and applied to the main trial, using data from patients receiving their randomized allocation in each group: i) entry criteria for centres; ii) entry criteria for surgeons; surgical protocols for key components of LAO and OO with mandated, prohibited and flexible components, monitored using iii) case report forms (CRFs) to record protocol adherence; and iv) intra-operative photographs to demonstrate protocol adherence (using the visible anatomical structures to determine if the component had been fully completed); and v) lymph node count and length of oesophagus.  

Results

8 centres and 39 surgeons participated and met entry criteria. 145 (LAO) and 149 (OO) patients underwent their randomized surgical procedure. Key procedural components were reported as complete in CRFs at similar rates in both groups, with >70% undergoing mandated components. However, adherence assessed using photographs was consistently lower than the CRFs. For example, left gastric artery lymphadenectomies were reported as complete in > 98% CRFs (LAO and OO) whereas photographs found this to be complete in 42% (OO) and 54% (LAO). Median nodal count was similar in both groups (145 LAO=24.7, SD = 10.6 and 149 OO = 26.4, SD = 10.2) as was length of resected oesophagus.

Conclusions

Assessing surgical QA in a multi-centre trial is logistically challenging but feasible. Whilst video data from laparoscopic cases could be collected and assessed, it was not possible with open surgery. Understanding adherence to the study protocol using photographs in addition to CRFs was important because of marked differences between what surgeons reported had been undertaken and images of what had been achieved. It is recommended that surgical trials include QA processes to understand protocol adherence and examine performance bias between groups.