bluuebunny/crossref_metadata_2025 huggingface dataset:
HPB O06 - A computer tomography-based radiomics signature predicts overall survival following curative resection of colorectal liver metastasis: A multicentre, retrospective study
Authors: Mian Areeb , Young Robert , Lakah Adil , Leptidis Ioannis , Jones Robert , Gordon-Weeks Alex
Published: November 2024

Background

Colorectal cancer liver metastasis (CRLM) has a heterogeneous outcome and improved prognostic biomarkers are needed to aid patient-tailored management. Here, we assess the value of Computer Tomography (CT)-guided radiomics in the prognostication of post-resection CRLM using data from two large tertiary referral centres in the UK.

Method

Patient data was extracted from prospectively maintained databases of patients undergoing CRLM resection at two centres. CRLM and regions of interest from background normal liver were segmented. Radiomics features were extracted from portal venous phase CT images using open-source software. Feature selection techniques were applied. Machine learning models incorporating radiomic or clinical features, and their combination, were developed and assessed for mortality prediction at fixed time points. Cox proportional hazard regression was utilised for risk score generation to classify patients as high or low-risk for overall survival estimation. The models were evaluated on unseen testing data.

Results

Radiomics features (269) were generated from 959 metastases in 399 patients across the two sites. Models with combined clinical and radiomic features performed similarly to those with radiomic features alone, and often outperformed models with clinical features alone demonstrating good discrimination and risk prediction at 2 and 3 years. The computed radiomic scores allowed us to generate Kaplan–Meier curves which showed CRLM patients in the high-risk group had a lower overall survival vs the low-risk group(p<0.05). This risk-score independently predicted mortality in our multivariate Cox proportional-hazards model.

Conclusion

We demonstrate a robust combination of CT-based radiomics features can predict CRLM outcomes across two different hospital sites. Our radiomic risk-scores predicts overall survival and can prognosticate patients into high and low risk groups. These findings support the prognostic utility of CT-based radiomics in patients undergoing resection of CRLM and provide rationale for further investigation in a prospective, multi-centre setting.
VS 08 - HPB Laparoscopic cholecystectomy for left-sided gallbladder – How not to do it?
Authors: Gada Parth , Viswanath Y K S
Published: November 2024

Background

Left-sided gallbladder (LSG) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament and round ligament without situs inversus. (1) The reported prevalence of sinistroposition ranges from 0.2% to 1.1%. (2) There are three recognized variants of LSG: LSG associated with situs viscerum inversus, true LSG, and gallbladder located to the left of abnormally located right-sided round ligament/ ligamentum teres.

Method

We present a case of a gentleman who was diagnosed as having gall bladder sinistroposition intraoperatively, after all the laparoscopic ports had been placed as per a routine laparoscopic cholecystectomy. Although the gentleman had undergone preoperative MRCP, it was not reported by the radiologists as such. The surgery was carried out using the usual ports used for standard four-port laparoscopic cholecystectomy and demonstrates the difficulty faced by the surgeon with these ports.

Results

Critical view of safety was demonstrated. Gall bladder was removed in piece meal. Surgery lasted for more than 90 minutes. There were no post-operative complications. Suggested modifications include Right working port from the Palmers point(3) or using a robotic approach with the same standard configuration(4). Our reflection revealed – interchanging of 5 mm and 12 mm working ports could have been helpful for better access.

Conclusion

The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. (5) The diagnosis is usually incidental and is done intraoperatively. Hence surgeons must be aware of these possibilities.
EDI&S SO02 The Aspire Initiative: A Community-Based Intervention to Champion Equality, Diversity and Inclusion in the Future Surgical Workforce
Authors: Kanani Trisha , Millard Alice , Robertson Francis , Issa Eyad , Bhardwaj Neil , Malde Deep , Dennison Ashley , Garcea Giuseppe , Isherwood John
Published: November 2024

Background

In March 2021, the Royal College of Surgeons of England published The Kennedy Report, an independent and powerful review addressing the critical issues surrounding equality, diversity and inclusion within the surgical profession. Chapter 5 of the review states that aspirations to become a surgeon can begin whilst at secondary school, yet students from diverse ethnic and social backgrounds felt discouraged by teachers who doubted their potential. We describe the development and implementation of a strategic careers outreach initiative across the state-funded secondary schools in our diverse community, aiming to engage and support aspiring surgeons early in their journey.

Method

In June 2023, The Aspire Initiative was launched as an independent entity supported by surgeons from the local Hepato-Pancreato-Biliary Unit and sponsorship from the Royal College of Surgeons of England. Targeting students aged 13 to 17, the initiative offers community open events, inspiring video content, surgical work experience for those over 16, and outreach careers assemblies. Between November 2023 and March 2024, 13 assemblies were delivered at various state-funded secondary schools across Leicester. These sessions were led by surgeons reflecting ethnic, gender, and socio-economic diversity. Students were invited to complete surveys before and after the assembly to assess their impact.

Results

The pre-session survey, completed by 874 students from Years 8-11, revealed that 149 aspired to be doctors or surgeons, while 243 were considering this (n=392). Of the 392 students, 57% reported that their parents had not attended university. Only 19% had a good understanding of the medical school application process, and 21% knew about the support available. Furthermore, 31% felt knowledgeable about the daily responsibilities and training pathways of medical professionals. The post-session survey, with 420 responses, showed significant improvements: 91% gained a better understanding of a surgical career and 52% felt more inspired and motivated to pursue their aspirations.

Conclusion

The Kennedy Report recommended that careers outreach to diverse communities should be planned for as a strategic priority. This study highlights the impact of such initiatives in state-funded secondary schools, showing how they provide students from diverse social backgrounds with crucial insights into surgical careers. These programs help students make informed decisions and inspire them to pursue their aspirations by connecting with relatable role models. We propose that engaging with students at the secondary school level offers an ideal opportunity for surgeons to foster and sustain professional relationships with a diverse future workforce, laying foundations for continued support and mentorship.
EDI&S SO04 Accuracy of Outsourced Radiology Reports in Emergency Surgical Care; Do they provide a high-quality cost-effective service?
Authors: Barghash Mohammed , Obayi Emmanuel , Aung Ye Htet , Furber Zoe , Haq Shua , Mansour Moustafa
Published: November 2024

Background

Computed Tomography (CT) scans play a crucial role in emergency surgical care enabling proper management and prompt decision making. In our study we aimed to compare abdominal CT scan reports created by inhouse radiologists to those created by outsourced radiology reporting service for patients admitted with acute surgical pathologies. The study also looked at the impact of the reporting style (free text or structured format) on the quality of scan reports.

Method

The study was conducted in a busy general surgery unit located in the North West of England. Patients who were admitted acutely under the surgical specialty and had abdominal CT scans over a period of three months from August 2023 to October 2023 were included. Patients who were admitted following trauma or had non abdominal CT scans have been excluded. Statistical analysis was conducted to compare inhouse radiology reports to outsourced ones. Scan reports were thoroughly scrutinised to identify whether they included all relevant information needed and whether they were written in structured or free text format.

Results

A total of 192 patients were identified with a median age of 59 years. Outsourced radiology reports were found to be significantly underreporting comments on the biliary system (OR=0.369, P=0.046), spleen (OR=0.414, P=0.044), kidneys (OR=0.354, P=0.027), lymph nodes (OR=0.412, P=0.011), mesentery and peritoneum (OR=0.364, P=0.004), vasculature (OR=0.381, P=0.002), bones and soft tissues (OR=0.273, P=0.003), as well as lung bases (OR=0.300, P=0.009). Structured format was found to outperform free text style on comments on spleen (OR=8.064, P=0.044), adrenals (OR=8.468, P=0.039), mesentery and peritoneum (OR=4.618, P=0.000), as well as bone and soft tissues (OR=9.295, P=0.031).

Conclusion

CT scans reported by outsourced radiology service were found to be significantly underreporting certain key elements. Additionally, free style reporting format was found to miss some crucial aspects of abdominal scan reports. That adds further challenges to clinicians assessing and managing acute surgical patients. Further studies auditing different outsourced companies are recommended to ensure patients are provided with high-quality cost-effective emergency service.
EDI&S SO07 Future of Low-Cost Laparoscopic Cholecystectomy Simulation (LaChSi) Model: Integration of Segmentation-Based Artificial Intelligence Models for Realism Enhancement in Simulation-Based Laparoscopic Cholecystectomy Training in Lower-Middle-Income Countries
Authors: Karki Bishow Bekhyat , Sharma Swodesh , Katuwal Sulav , Satyal Sanjivan , Loubani Prof Mahamud
Published: November 2024

Background

To introduce an approach of employing segmentation-based Artificial Intelligence (AI) models to meticulously isolate the silicon-based Laparoscopic Cholecystectomy Simulation Model (LaChSi) model within the laparoscopic trainer box, thereby enhancing realism. To assess the effectiveness of the AI Model to track camera angles to seamlessly replace the background with a virtual environment reminiscent of authentic intra-operative intra-abdominal visuals.

Method

The proposed methodology integrates a sophisticated segmentation model that identifies and accurately delineates the LaChSi Model within the laparoscopic Trainer box. Simultaneously, the model exhibits the capability to segregate the background, while closely monitoring camera angles for real-time adjustment. Importantly, the model is trained to perform precise segmentation of surgical tools, ensuring a comprehensive and realistic representation of the laparoscopic environment.

Results

Implementation of the proposed method is thought to demonstrate a notable improvement in trainees’ adaptation to surgical scenarios. The visual transition experienced by trainees moving from simulation-based surgeries to actual surgical environments will significantly reduce disparities increasing the effectiveness of the Laparoscopic simulation training. This will further avoid the need to use sensors and wires on the LaChSi model to simulate the surgical settings.

Conclusion

As the visual representation in simulations often deviates substantially from the intricate nuances of actual surgical procedures. This study introduces an innovative AI-based model that will contribute to the augmentation of surgical realism within simulation-based training. By effectively integrating segmentation techniques, our approach will minimise visual discontinuities, providing trainees with a more authentic and immersive experience, and ultimately fostering a smoother transition to acute surgical settings.
BS SO14 - Is there a correlation between preoperative HbA1c changes and long-term weight loss plus glycemic control in patients with type 2 diabetes undergoing metabolic surgery?
Authors: Tempany Jennifer , Collier Professor Andrew , Ali Professor Abdulmajid
Published: November 2024

Background

Optimization of patients with type 2 diabetes mellitus (T2DM) prior to metabolic surgery aims to achieve tight glycemic control by the time of surgery. Little is known about the influence of altering preoperative HbA1c on postoperative weight loss and glycemic control. The aim of this study was to determine whether a change in HbA1c during the preoperative period correlated with long term weight maintenance and HbA1c in patients undergoing metabolic surgery. The proportion of glucose-lowering medication used following surgery was also examined.

Method

Retrospective analysis was conducted of patients with T2DM who underwent metabolic surgery between 2013 – 2017. Preoperative HbA1c change was measured as change in glycemic control during the 1-year pre-surgery. Primary outcomes were % excess weight loss (EWL) and HbA1c at 5 years post-surgery. Secondary outcomes were % EWL and HbA1c at 1-year post-surgery and the use of glucose-lowering medications post-surgery. The Pearson correlation coefficient (r) was used to determine the relationship between the pre-surgery HbA1c change and postoperative % EWL and HbA1c. Chi-squared test was used to calculate the statistical impact of change in medication use post-surgery

Results

Sixty-nine patients with complete data were included in the study. The mean change in HbA1c in the 1-year pre-surgery, the 1-year post-surgery and 5-years post-surgery was -0.9% (± 1.5), -0.7% (± 1.2) and 0% (± 1.8), respectively. The change in HbA1c in the 1-year pre-surgery did not correlate with % EWL at 1-year and 5-years post-surgery or with HbA1c at 1-year and 5-years post-surgery. There was a significant decrease in the proportion of patients requiring glucose-lowering medications at 1-year and 5 years post-surgery (p<0.05).

Conclusion

This study demonstrated a significant reduction in the proportion of glucose-lowering medication required long-term following metabolic surgery. Altering pre-operative glycemic control was not associated with long term weight maintenance or glycemic control.
BS SO15 - Outcomes of Braun procedure for reflux after OAGB- Audit from a single center
Authors: Haider Ijlal , Kaur Mandeep
Published: November 2024

Background

Braun procedure is a procedure used for management of reflux in gastric bypass patients. It is a simple procedure offering a jejuno-jejunal anastomosis to bypass bile away from stomach to prevent symptoms of reflux. It has been used in cancer patients needing bypass surgery. This has also been used in One anastomosis gastric bypass patients presenting with reflux.

Method

We would like to present the steps of Braun procedure. At the same time, we would like to take this opportunity to present the results of our audit of patients presenting with bile reflux needing surgical management of symptoms.

We analysed our operation sheets from December 2016- Jan 2024 and retrospectively looked into the patients who needed surgical management of bile reflux.

Results

Total number of OAGB procedures done –1024, out of these 30 patients presented with bile reflux needing surgical management. 26 of these 30 patients underwent Braun procedure and 4 underwent RYGB. 6 patients out of the 26 patients who underwent Braun procedure needed conversion to RYGB because of non-resolution of symptoms.

Since we looked at operation sheets, we have not analysed the total number of patients who have reflux post OAGB.

Conclusion

Conversion to RYGB is the gold standard procedure for managing bile reflux after OAGB. Braun’s procedure is a simpler procedure which can be done as day case and suffices in 86 % of patients. Patients should be offered both the procedures.
BS SO19 - Left Paraduodenal Hernia - Laparoscopic reduction and repair
Authors: Ravichandran Madhumitha , Kannan Shanmuga , Niaz Osamah , Munasinghe Aruna
Published: November 2024

Background

We present a case of a 39 year old female patient, with a BMI of 37.5 and a background of hypertension scheduled for a bariatric gastric sleeve surgery. During the surgery, incidentally, a left paraduodenal hernia was identified. The incidence of a left paraduodenal hernia is 0.03% of all hernias, which makes it a rare case to present.

Method

The hernia with all it contents was reduced. The defect was visualised and repaired. Haemostasis achieved.

Results

The postoperative period was uneventful. The patient was followed up regularly in the bariatric clinic with no further complaints.

Conclusion

In conclusion, this case highlights the incidental discovery and successful management of a rare left paraduodenal hernia in a 39-year-old female patient undergoing bariatric gastric sleeve surgery. Despite the rarity of this type of hernia, with an incidence of 0.03% of all hernias, prompt intervention led to a favorable outcome. The postoperative course was uneventful, and the patient reported no further complaints during regular follow-ups in the bariatric clinic. This case underscores the importance of vigilance for unexpected findings during surgery and demonstrates the successful resolution of such rare occurrences through careful surgical management.
EGS SO02 - The undifferentiated general surgical take over 10 years: Admissions
Authors: Dean Lydia , Hale Emily , Bowling Kirk
Published: November 2024

Background

Hospital admissions in England and Wales have been increasing over time. This increase has occurred across many specialties, including across the surgical specialties. The aim of this study is to review the undifferentiated emergency general surgical take, with regards to admissions in July 2013 and July 2023, at a District General Hospital to understand the specific pressures on the department and to identify areas in which we could adapt to facilitate these demands.

Method

Retrospective data regarding admission and re-admission on all patients treated by the emergency general surgical team in July 2013 and July 2023 was collected from electronic notes. If insufficient information was available, patients were excluded from analysis.

Results

Patient numbers increased by 50% from 2013 to 2023, from 395 to 594. Average length of stay in 2013 was 3.26 days (+/-0.2, p = 0.03), reducing to 2.58 days (+/-0.2, p = 0.03) in 2023. Number of patients admitted overnight has decreased from 74% (n=291/395) in 2013, to 54% (n=324/594) in 2023. Proportion of referrals from ED increased from 48% in 2013, to 69% in 2023. Planned reviews and patients ambulated for surgery the following day has increased from 4% of all patients seen in 2013, to 16% in 2023.

Conclusion

Volume of patients has increased significantly over this 10-year period. Simultaneously, duration and number of overnight admissions have decreased, alongside increasing use of ambulatory services. This reflects the aims of the Government, and the Royal College of Surgeons, with increasing investment in day-case and ambulatory services. However, without an increase in hospital bed numbers, the rising volume of patients may become difficult to manage.
EGS SO05 - Improving the Flow of Patients Attending Surgical Assessment Unit: Introduction of Ambulatory USS Slots - Closed Loop Audit
Authors: Yershov Danylo , Stylianou Theodoros , Hirri Faith , Findlay Laura
Published: November 2024

Background

Modern emergency surgical service recognises that a significant proportion of patients presenting with acute abdomen can be diagnosed and treated in the ambulatory fashion. However, this approach requires multidisciplinary cooperation between the general surgery team and radiology department. We aimed to assess and improve the flow of patients presenting to Surgical Assessment Unit (SAU) with complaints of right iliac fossa (RIF) and right upper quadrant (RUQ) pain.

Method

We performed a retrospective analysis of all ambulatory patients returning to SAU of a District General Hospital with RUQ and RIF pain in January 2023. We measured the waiting time between the arrival to SAU and the time of USS. We presented the results in a local meeting and negotiated the introduction of two daily USS slots for SAU patients. We re-assessed the impact of the USS slots on waiting times in July 2023.

Results

In January 2023, 13 patients returned to SAU for USS. The minimum waiting time for this cohort was 59 minutes and the maximum waiting time was 3 hours and 39 minutes. The median was 2 hours and 15 minutes. In July 2023, 18 patients returned to SAU for USS. The minimum waiting time for this cohort was 4 minutes and the maximum waiting time was 2 hours and 20 minutes. The median was 1 hour and 5 minutes. There was an average reduction of 1 hour and 10 minutes in waiting time for USS.

Conclusion

The introduction of two USS slots per day for patients returning to SAU with RUQ and RIF pain resulted in a 48% reduction in waiting times. This improved the flow of patients, sped up the diagnosis and timely access to treatment, as well as significantly improved patients experience and satisfaction. We would recommend close co-operation between general surgery and radiology to allow timely access to imaging for patients presenting with acute abdomen to SAU.
EGS SO09 - Documentation Of Mortality While Consenting For Major Emergency Operation In General Surgery : Are We Informing Patients Or Just Impressing NELA? A Three-Cycle Clinical Audit
Authors: Isswiasi Sanad , Esawi Ahmed , Anwaar Muhammadhasan , Lord Ian
Published: November 2024

Background

Approximately 30,000 to 50,000 emergency laparotomies are performed annually in the United Kingdom (UK), with an in-hospital mortality rate of 9.2%. The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report from 2011 recommends that the risk of mortality should be explicitly discussed with patients and clearly documented on consent forms and in medical records. The purpose of our audit was to assess the frequency of documenting the risk of mortality in consent forms and to evaluate the reporting of corresponding discussions in the medical records of patients undergoing major emergency general surgical operations.

Method

Patients were identified from our National Emergency Laparotomy Audit (NELA) database, and data was collected retrospectively from our online medical records. We included procedures from NELA performed on patients aged 16 and older who had the capacity to give consent. The first audit cycle took place from April to June 2021, the second from March to May 2022, and the third from March to May 2023. The results of the first cycle revealed gaps in documentation, leading to the implementation of periodic reminders for surgeons during meetings and the use of posters to reinforce best practices.

Results

The 1st cycle included 40 cases, with 93% documented mortality in NELA, 40% in consent forms, and 35% documented discussion about mortality in medical notes. The 2nd cycle reviewed 38 cases, showing 92% documented mortality in NELA, 71% in the consent forms, and 42% of documented discussion about mortality in the medical notes. The 3rd cycle assessed 32 cases, with 90% documented mortality in NELA, 92% in consent forms, and 51% in the medical notes. The improvement in documentation of the risk of death in the consent forms was statistically significant across all three cycles (p < 0.0001).

Conclusion

The three audit cycles demonstrated that implementing periodic reminders and posters for surgeons significantly improved the documentation of mortality risk. Documentation rates in consent forms increased from 40% in the first cycle to 92% by the third cycle, and in medical notes from 35% to 51%. These interventions effectively enhanced compliance with best practices. However, continuous effort is essential to maintain this improved practice. Regular monitoring, ongoing education, and reinforcement strategies should be employed to ensure that the documentation standards remain high and continue to improve patient care and safety.
EGS SO14 - Tip First vs. Base First approaches in appendicectomies
Authors: Agrawal Kapil , Kaur Jaspreet Singh , Liu Ben
Published: November 2024

Background

Appendicectomies are common. Techniques can be classified into tip-first (stripping the appendix off the mesoappendix) or base-first (ligating the base of mesoappendix), where the latter includes the entire mesoappendix in specimens. This study examines these two techniques and compare their pathological and clinical outcomes, noting that tip-first technique leaves mesoappendices behind.

Method

This retrospective study classifies the two techniques of appendicectomies according to histological analyses where the tip-first approach produced no mosoappendix in the specimen. We investigated:Baseline characteristics: Age, gender, ASA-grades, emergenciesOperative differences: Surgeon grades, operating duration, laparoscopic ratesThe pathological outcomes: specimen length, presence of malignanciesClinical outcomes: Post-op stay, further treatments

Results

Over 12-months, 134 consecutive appendicectomies were identified (94 base-first and 40 tip-first), without significant baseline differences, although the base-first group were notably older (p=0.051). Laparoscopic rates and operating times were comparable. There were significantly higher number of consultant-led operations in the base-first group: 41.5% vs 22.5% (P=0.036). The appendix specimen is insignificantly longer in the base-first group (P=0.477). Five incidental malignancies were found, of which 2(5%) were in the tip-first group. Without the mesoappendix, completeness of excision was indeterminate and subsequent right hemicolectomies were performed. Lengths of stays were not significantly different.

Conclusion

We found preference of tip-first appendicectomies among junior surgeons while consultants favour base-first approaches, which may be attributable to experiences and trainings. Two tip-first appendicectomies resulted in incomplete staging of incidental malignancies which necessitated further surgical resections. We conclude base-first appendicectomies should be taught to all trainee surgeons.
EGS SO18 - Entero-enteric intussusception secondary to a capillary haemangioma of the small bowel: A case of a diagnostic conundrum
Authors: Asour Amani , Massella Virginia , Azad Mohd , Raza Mehdi
Published: November 2024

Background

This is a case of a 50 year-old female who presented with acute on chronic abdominal pain, and she was intra-operatively diagnosed with entero-enteric intussusception secondary to a large small bowel tumour . The video demonstrates the findings during the diagnostic laparoscopy. The lead point appeared to be a tumour and histopathology confirmed it is a benign capillary haemangioma. The patient had a long standing history of abdominal pain that was previously investigated on multiple occasions, but without a definitive diagnosis.

Method

This is an interesting case of a challenging diagnosis of a rare disease. The patient has been suffering for four years with unexplained upper abdominal pain not associated with weight loss, rectal bleed, or change in bowel habit, but had occasional anaemia. The patient had a normal abdominal US, multiple CTs where she was found to have a right renal stone and an OGD that showed gastritis and positive CLO test initially. A repeat OGD and colonoscopy were negative. While the patient was awaiting further investigations for profound iron deficiency anaemia she presented with acute abdomen and required emergency surgery.

Results

The patient presented to ED with excruciating colicky pain for one day, one episode of melena and nausea. She was haemodynamically stable, peritonitic with increased inflammatory markers, hb 86 g/dL and lactate of 2 mmol/L. The CT abdomen and pelvis showed small bowel intussusception with possible ischemia, therefore the patient underwent an emergency operation.The laparoscopy showed small bowel intussusception and the patient underwent mini laparotomy. The intussusception was reduced, the small bowel was viable and the lead point was a large size tumour.The patient underwent small bowel resection and primary anastomosis, and made good post operative recovery.

Conclusion

Rare conditions are hard to diagnose. Small bowel intussusception is rare and in adults is usually linked to serious underlying pathology. Capillary haemangioma of the small bowel is very rare too. The patient's symptoms and occassional anaemia can now be explained. Although the patient went through an appropriate work up at the time, her symptoms remained unexplained to some extent or they were linked to other potential causes. Only when the anaemia became profound the patient warranted further investigations. In retrospect, capsule endoscopy would have been inevitable, however the patient became acutely unwell and required an emergency surgery.
EGS SO24 - Endoscopic Vacuum Therapy for Oesophageal Perforation and Anastomotic Leaks
Authors: Alam Mushfique , Raychaudhury Arun , D’Souza Joel , Bird Nick , Rao Rohith , Gunasekera Rohan , Howes Nathan , Stephens Nathan , Dexter Eloise
Published: November 2024

Background

Oesophageal perforations and oesophago-gastric (OG) anastomotic leaks are challenging conditions, associated with significant morbidity and mortality. In recent years, endoscopic vacuum (EndoVac) therapy has emerged as a novel, alternative intervention for source control and to promote healing. Introduced to our unit in 2019, this cohort study presents our experience with EndoVac management of both post operative OG anastomotic leaks and primary oesophageal ruptures.

Method

Retrospective analysis of patient electronic records was conducted for all patients who received EndoVac management between the study period of October 2019 to June 2023. Pertinent outcome variables included length of vacuum therapy, number of changes, length of admission, in hospital and 90 day mortality rates.

Results

37 patients were identified within the study period. The average age of this study cohort was 68 years with a mode ASA of III. The most common indication for EndoVac therapy was anastomotic leak (56%), followed by oesophageal perforation (31%). Defect resolution was achieved in 72% of patients. The median duration of treatment was 26 days (range 2-157), whilst the median number of changes was 7 (range 2-31). The overall in hospital complication (Clavien Dindo I-V) rate was 34%. The 90-day mortality rate was 22% whilst the morbidity rate was 13% in the form of anastomotic stricturing requiring serial dilatations.

Conclusion

EndoVac therapy is an effective minimally invasive treatment for post operative OG anastomotic leaks and oesophageal ruptures. With ongoing expansion in it’s use in our unit and throughout the UK, further work is required to assess the long-term outcomes and develop guidelines around its use in both oesophageal leaks and perorations.
OGC SO09 - Embracing change: Reproducible protocol for enhanced recovery after esophagectomy
Authors: Hassn Ahmed , Bahery Mohamed , Saad Reda
Published: November 2024

Background

Esophagectomy for cancer of the oesophagus is a complex surgery with significant morbidity. Protocols have been proposed to enhance recovery and reduce morbidities after this surgery.

A decade ago, we have introduced major changes to the traditional perioperative management of esophagectomy patients and have been able to introduce these changes and reproduce the same results in three different countries.

Method

While working in the NHS, the main author has introduced many changes in the perioperative management of esophagectomy patients.

The major changes included: 1- Injection of 200 units of Botox into the pylorus in the week prior to surgery. 2- No use of thoracic epidural and use of intercostal block instead. 3- Hybrid minimally invasive esophagectomy(HMIO) (Laparoscopic abdominal part and right thoracotomy). 4- Use of Heimlich valve instead of under-water seal bottle. 5- Avoidance of Opiate use and walking the patient on day 1 postoperatively.

These changes were introduced in two other countries namely; Egypt and Dubai.

Results

We studied 151 consequtive cases of esophagectomy from January 2014 till April 2024 (102 cases were performed in NHS Wales and 49 cases were performed in Egypt and Dubai).

Median age was 69 and range of 38 - 83 years. 94% had adenocarcinoma and 88% were stage 2b -3b. Neoadjuvant chemotherapy were given to 91% of patients.

All patients had the described changes applied.

Overall complication rate is 17.2% with Clavien-Dindo score of ≥ 3a in 8%. Anastomotic leak and 90-day mortality were 2.6%. Median hospital length of stay is 5 days.

There were no difference of outcomes in the three countries.

Conclusion

Preoperative injection of Botox into the pylorus, use of Heimlich valve instead of under-water seal bottle, use of intercostal block instead of thoracic epidural and avoidance of Opiate use when applied to HMIO significantly improve the short-term outcomes after esophagectomy.

These changes and outcomes are reproducible.
OGC SO17 - Right lateral approach to left gastric pedicle and Usage of articulated Signia Tri-stapler in Laparoscopic abdominal phase of a 2-stage Oesophagectomy
Authors: Loh Yong Yang Danielle , Kwan Xin Yi , Pua Qiao Ying , Viswanath Yirupaiahgari K S
Published: November 2024

Background

Advancements in oesophagectomy surgery over the past decade has seen an increase in minimally invasive oesophagectomies (MIE) being performed. Studies showed MIE had considerable advantages over open oesophagectomy by reducing intraoperative blood loss and post-operative complications while maintaining similar oncological outcomes1. In the abdominal phase of the Ivor-Lewis 2-stage oesophagectomy, a posterior approach is commonly used to dissect posterior gastric and left gastric vessels2.

Method

A 40-year-old patient with early malignant lesion underwent laparoscopic 2-stage oesophagectomy. In this video, we demonstrate using a right lateral approach to access and divide the left gastric vein and artery. Lymphadenectomy of stations 7 and 8a was also completed. A pyloroplasty is performed along with fashioning a gastric conduit using an articulated Signia tri-stapler, a smart stapler that adapts in real-time to tissue variability.

Results

The right lateral approach is superior to the more commonly used posterior lesser sac approach as it provides visuals of key vessel structures and spleen thereby reducing the risk of injury and bleeding. In the second stage, the Signia tri-stapler allows precise manoeuvres with fully powered articulation, rotation, and clamping, resulting in consistent staple lines and stronger staple lines.

Conclusion

Oesophagectomies remain a highly technical surgery with varied practices across centres and we would like to propose using a right lateral approach and articulated tri-stapler as a better technique that would reduce risk of bleeding and leaks.
OGC SO21 - Role of Staging Laparoscopy on oesophageal and junctional cancer management
Authors: Tokhi Ashraf , Reid Eleanor , North Samuel , Clarke Simone , Vohra Ravinder , Parsons Simon
Published: November 2024

Background

Staging laparoscopy and peritoneal cytology is currently recommended as a staging tool required for oesophageal and gastro-oesophageal junction (OGJ) adenocarcinomas. However, evidence is variable regarding the utility of this investigation, leading to heterogenous practice in the UK. With improved staging sensitivity of CT and PET imaging and inclusion of routine MDT discussion for upper GI cancer patients, staging laparoscopy may not be necessary for all patients with oesophago-gastric cancer, and in fact may delay their treatment. We thus aimed to assess the impact of staging laparoscopy on the treatment algorithm of patients with oesophago-gastric cancer.

Method

All staging laparoscopies undertaken between January 2022 and March 2024 were identified from our surgical database. Patients were included if they had oesophago-gastric adenocarcinoma, with a plan for curative treatment. Data collected included age, gender, location of primary tumour, CT/PET staging, laparoscopy findings, impact on treatment intention, neoadjuvant treatment, and final histology. Primary outcome was incidence of positive microscopic or macroscopic peritoneal disease for oesophageal and OGJ malignancy.

Results

127 patients were identified - 69 (55%) oesophageal, 25 (20%) GOJ, and 32 (24.4%) gastric cancer. 1/70 (1.4%) patient diagnosed endoscopically with oesophageal cancer had positive peritoneal disease, which was suspected due to pre-operative imaging findings of ascites and suspicions of linitis plastica. Of patients diagnosed with GOJ cancer, 4/25 patients (16%) had peritoneal disease present. None of the 39 patients with oesophageal/junctional tumours with clinical T1-2 disease were found to have peritoneal disease on staging laparoscopy. 6/32 (19%) patients with gastric cancer were found to have unexpected peritoneal disease present.

Conclusion

This study found minimal impact staging laparoscopy has on the management of primary oesophageal cancers. Consideration can be made of limiting staging in oesophageal cancer to patients with suspicious findings on CT/PET imaging. For GOJ tumours, there may be a role for limiting staging laparoscopy for Siewert 1 tumours to T3/4 tumours based on CT/PET findings. Importantly, accurate identification on primary endoscopy of the location of the tumour in relation to the gastro-oesophageal junction is necessary to help guide ongoing management.
OGC SO31 - Treatment of cachexia in gastric cancer: A literature review exploring the use of natural anti-inflammatory products and their derivatives
Authors: Loyala Jerocin , Down Billy , Wong Enoch , Tan Benjamin
Published: November 2024

Background

Gastric cancer is a major cause of global cancer-related mortality, with 5-year survival rates of 7% in advanced disease. Cancer cachexia, characterised by irreversible skeletal muscle loss driven by systemic inflammation, contributes to approximately 20% of cancer-related deaths. Cachexia differs from malnutrition in that it cannot be fully reversed with nutritional support alone. Current treatments that focus on nutritional support, psychological counselling and anti-inflammatory medication are lacking in efficacy. Natural dietary supplements and their derivatives such as fatty acids, probiotics, amino acids, curcumin, ginger and resveratrol, may offer additional therapeutic benefits in managing gastric cancer cachexia.

Method

A comprehensive literature review was conducted to evaluate the efficacy of natural anti-inflammatory products in managing gastric cancer cachexia. The review focused on widely studied compounds including omega-3 fatty acids, probiotics, amino acids, curcumin, fucoidan, epigallocatechin-3-gallate (EGCG), resveratrol and ginger, assessing their impact on inflammation, muscle mass preservation, and overall patient outcomes.

Results

Natural anti-inflammatory compounds demonstrate efficacy in mitigating cancer cachexia by reducing systemic inflammation and muscle wasting. Essential fatty acids from nuts, seeds, and fish oil decrease pro-inflammatory cytokines and improve chemotherapy tolerance. Probiotics reduce gut dysbiosis and may enhance chemotherapy tolerance. Essential amino acids may promote muscle anabolism and reduce catabolism. Curcumin, fucoidan, EGCG and ginger exhibit anti-inflammatory properties, with some improving appetite and reducing nausea. While promising, these compounds need further clinical trials to validate their efficacy and safety in cancer cachexia management.

Conclusion

Natural anti-inflammatory products hold promise as adjunctive therapies in management of gastric cancer cachexia. While preclinical evidence is encouraging, robust clinical trials are essential to confirm their efficacy and safety. Integrating these compounds with conventional treatments may offer a comprehensive approach to addressing the complex metabolic and inflammatory challenges of cancer cachexia, potentially improving patient outcomes. Future research should focus on understanding mechanisms, optimising dosages, and overcoming bioavailability challenges.
OGC SO32 - Propensity score analysis of the impact of deprivation and the COVID-19 pandemic on Upper Gastro Intestinal (UGI) cancer surgery outcomes
Authors: Herbert Geraint L , Abdelrahman Tarig , Powell Arfon , Witherspoon Jolene , Foliaki Antonio , Blackshaw Guy , Khalid Usman , Lewis Wyn G
Published: November 2024

Background

Deprivation is a complex, multifaceted concept, not synonymous with poverty, but with the potential to widen health inequalities. This study aimed to explore demographic disparities in patients undergoing UGI cancer surgery in a UK regional cancer network during the COVID-19 pandemic.

Method

Consecutive 881 patients were studied prospectively (median age 67 (24 - 89) yr., 703 m, 178 f; 518 oesophageal, 363 gastric; 837 Adeno-, 44 SCC) over 13 years. The COVID-19 pandemic was defined as the 24-month period from February 1, 2020 to January 31, 2022, during which 118 patients were treated. The demographic profile of the pandemic cohort was compared with that of the 763 patients treated outside this period incorporating a propensity score analysis. Primary outcomes were operative morbidity, mortality, and one-year survival. Wales’ Index of Multiple Deprivation was used to assess deprivation disparity.

Results

A 24% reduction in the number of cancer operations was observed during the first pandemic year. No difference was observed in age, gender, histology, tumour site, ASA grade, or oncological treatment. During COVID-19 the proportion of patients from the two most deprived quartiles receiving potentially curative surgery fell from 53.2% to 40.7% (p=0.012). No difference was observed in severe morbidity (Clavien-Dindo >3, 22.2% vs. 19.8%, p=0.897), 30-day mortality (2.5% vs. 2.4%, p=0.886), or one-year survival (82.4% vs. 78.8%, p=0.374).

Conclusion

UGI cancer surgery safely continued during COVID-19, but patients from areas of high deprivation were over 20% less likely to access curative surgical treatment compared with before and after COVID-19. This emphasises the need for bespoke strategies to mitigate the disproportionate impact of any future pandemic on patients living in deprived geographical areas.
OGC SO37 - Pyloric drainage interventions for delayed gastric conduit emptying after oesophagectomy: A single centre analysis
Authors: James Eleanor , Santoro Giovanni , D’Souza Joel , Alam Mushfique , Bird Nicholas , Rao Rohith , Stephens Nathan , Gunasekera Rohan , Howes Nathan
Published: November 2024

Background

Oesophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for resectable oesophageal cancer. Delayed gastric emptying (DGE) is a common postoperative complication that results from the anatomical and physiological changes in the gastric conduit after an oesophageal resection. It is associated with an increased risk of pneumonia, anastomotic leak and prolonged hospital stay. Although several prophylactic pyloric drainage interventions have been postulated to mitigate the risk of DGE, the optimal modality remains debatable. This study aimed to define the incidence, evaluate prognostic factors, and characterise the management of DGE following oesophagectomy.

Method

Consecutive patients who underwent an oesophagectomy for oesophageal cancer between January 2022 and March 2024 were retrospectively identified from a hospital database. Pyloric drainage procedures consisted of expectant management, endoscopic/open pyloric Botox and pyloroplasty. Univariable and multivariable analyses were performed to define the incidence of DGE after each pyloric drainage modality, evaluate prognostic factors for DGE, and characterise the need for subsequent intervention in the management of DGE.

Results

The study cohort comprised 137 patients – mean age 66 years, male 78%. The incidence of DGE was 31%. Pyloroplasty had the lowest incidence of DGE (16%) followed by endoscopic botox (21%). Intra-operative pyloric drainage reduced the risk of DGE (p=0.03). The modality of prophylactic pyloric drainage used significantly influenced the risk of developing DGE (p=0.028). No significant differences were identified between patient demographics, operative approach, and oncological variables in the development of DGE. On multivariable analysis, pyloroplasty was associated with a reduced risk of DGE (OR 0.27, 95% CI 0.09 – 0.71). DGE did not influence overall survival.

Conclusion

DGE is a common postoperative complication which affects up to 39% of patients undergoing oesophagectomy. Patients who did not undergo a prophylactic pyloric drainage procedure during the index oesophagectomy were at an increased risk of developing DGE. Most patients with DGE (71%) require further intervention via endoscopy and botox injection. Pyloroplasty as a prophylactic drainage modality significantly reduced the risk of developing DGE compared to endoscopic botox. Further prospective randomised controlled trials are required to validate these findings.
OGC SO45 - Effect of anastomotic technique on leak rates in two-stage robotic-assisted subtotal oesophagectomy
Authors: Cross Andrea , Brown Joshua , Phillips Alexander , Wahed Shajahan , Immanuel Arul
Published: November 2024

Background

Introduction of new surgical techniques requires constant monitoring and real time audit. In our unit the introduction of the thoracic component of our robotic oesophagectomy program resulted in an increase in the anastomotic leak rate which was recognised in real time. This prompted a decision to change from a circular to a linear stapled technique. The aim of this study was to evaluate the impact of this change in technique on the anastomotic leak rate.

Method

A database was used to identify all cases of patients undergoing two stage subtotal oesophagectomy where the thoracic phase was performed robotically-assisted. Demographic, operative, pathological and complications data were extracted. An anastomotic leak was defined as radiological or endoscopic disruption of the oesophagogastric anastomosis or where a clinician had documented the presence of a leak in the clinical notes. Leaks were then graded by severity according to the classification by Low et al into type 1: localised defect treated with medical therapy or observation; Type 2: localised defect requiring intervention but not surgery, and; Type 3: localised defects requiring surgery.

Results

Fifty-seven patients were identified. The first 25 cases were reconstructed with a circular-stapled and the subsequent 32 with a linear-stapled anastomosis. There were no differences in baseline demographics. There were no differences in thoracic operating time nor blood loss, intraoperative complications and pathological variables such as lymph node yield. Overall, 11/57 patients (19%) had an anastomotic leak, of which 7 (28%) had a circular stapled anastomosis and 4 (12%) had a linear stapled anastomosis. This difference was not statistically significant (p=0.2384). However, CUSUM analysis after the change in anastomotic technique showed an ongoing and diminished anastomotic leak rate.

Conclusion

In our unit changing from a circular to a linear stapled anastomotic technique resulted in a reduction in the anastomotic leak rate from 24% to 12%. While this was not statistically significant, this is a clinically appreciable result and this benefit was confirmed on CUSUM analysis.