bluuebunny/crossref_metadata_2025 huggingface dataset:
HPB P41 The incidence and diagnostic potential of Extra-biliary findings on Magnetic Resonance Cholangiopancreatography
Authors: Tan Chin K , Wong Mei K , Kee Ng Shou , Stevenson Carla , Shahzad Khan Khurram
Published: November 2023

Background

Magnetic Resonance Cholangiopancreatography (MRCP) is increasingly utilised to assess the biliary tree. This imaging modality can potentially reveal extra-biliary findings that will warrant further urgent investigations. The primary aim of this study was to assess the prevalence of extra-biliary findings on MRCPs. The secondary aim was to assess the need for subsequent investigations and subsequent outcomes.

Methods

This was a retrospective cohort study of all consecutive MRCPs performed on adult patients in a single centre form September 2021 to September 2022.

Patient demographics, indication(s) for MRCP, MRCP result including extra-biliary findings were analysed from electronic case notes. Further analysis of necessary investigations into these extra-biliary findings and outcomes was also undertaken. This study was registered with Clinical Quality Project (LanQIP 14742).

Results

495 MRCPs were performed in the study period; 305 (61.6%) were female; median age was 63 years (IQR 50-74). 311 (62.8%) were inpatient and 200 (40.4%) were urgent. 61.2% (n=303) had at least one extra-biliary finding and 8.1% (n=44) required urgent follow-up with 12 having a new diagnosis of malignancy.

19.4% (n=96) had renal cysts, 12.7% (n=63) had hepatic cysts, 5.6% (n=28) had pancreatic cysts, 2.8% (n=14) had liver cirrhosis, 2.8% (n=14) had peripancreatic collections, 3.4% (n=17) had a hiatus hernia, 7.3% (n=36) had pleural effusions, 5.3% (n=26) had splenomegaly and 1.8% (n=9) had identified diverticular disease.

Conclusions

Each of the extra-biliary findings on MRCP were confirmed with further investigation, which again highlights the high accuracy of Magnetic Resonance Imaging (MRI). It is undeniable that MRCPs are revealing extra-biliary findings which indicate that the diagnosis potential of MRCPs is underestimated. Although MRIs are widely used and has no ionising radiation unlike Computerised Tomography (CT) scans, they are still more costly. Furthermore, it was also noted in previous studies that incidental findings are largely dependent on the reporting radiologist and a structured proforma might be beneficial moving forward.
HPB P44 Case Report: Retrograde transhepatic duodenal and antegrade common bile duct stenting in malignant duodenal stricture
Authors: McWade Megan , Murch Cliff , Shahzad Khan Khurram
Published: November 2023

Background

Duodenal adenocarcinoma is a rare and aggressive malignancy, that unfortunately often present late meaning diagnosis can be delayed and commonly have no curative surgical options available. Patients with non resectable disease typically have a life expectancy from 2-8 months. In these palliative patients, antegrade stenting of the malignant stricture can effectively relieve symptoms of gastric outlet obstruction. We present retrograde transhepatic duodenal stenting in a patient where antegrade stenting had failed.

Methods

A 68 year old woman presented with abdominal pain, vomiting and weight loss, was found to have gastric outlet obstruction on imaging and subsequently diagnosed with D1 duodenal adenocarcinoma. Multiple attempts at dilatation had failed and one failed attempt at antegrade stenting to relieve their symptoms. A novel technique of retrograde transhepatic stenting of duodenal stricture and antegrade common bile duct (CBD) was then successfully performed with no post procedure complications. Not only did this help alleviate the patients’ symptoms but allowed subsequent antegrade passage of a D3 stent from a subsequent obstruction.

Results

Retrograde transhepatic duodenal stenting was carried out under general anesthesia with a right percutaneous puncture to pass a guide wire into the intrahepatic ducts, then the CBD narrowing followed by the duodenal stricture. The duodenal stricture was then stented followed by the CBD stricture and a drain left in the common hepatic duct.

Conclusions

Although duodenal adenocarcinoma is rare, it should be considered in all patients with suspected gastric outlet obstruction. A multidisciplinary team approach is necessary in managing patients with duodenal strictures. Retrograde transhepatic duodenal should be considered in palliative patients when antegrade stenting fails.
HPB P50 A comparison of layered vs mass closure in development of incisional hernia following Kocher’s incision for open cholecystectomy, a retrospective analysis
Authors: Korolchuk Mykola , Azam Muhammad , Satchidanand Rajesh
Published: November 2023

Background

Incisional hernias are a common complication of abdominal surgery. Open cholecystectomy procedures predispose to development of incisional hernias. Studies have shown rates of incisional hernias in visceral abdominal surgery to be 12.6% at one year and 22.4% at 3 years [1]. Several techniques have been developed to reduce rates of incisional hernia, namely abdominal wall closure in layers rather than mass closure. The purpose of our study is to evaluate whether layered closure is superior in preventing incisional hernias compared to mass closure.

Methods

The study reviewed retrospective data on 694 cholecystectomies at Southport or Ormskirk NHS Trust between 2018-23. Of these cases, 104 underwent open procedures. Operation notes and follow up were accessed electronically and analysed. Patients were also contacted by telephone to further establish whether they have developed incisional hernias and discuss other complications following surgery. The primary objective was to compare hernia rates between mass and layered closure. Secondary objectives were to establish hernia incidence in relation to gender, age, BMI, and elective vs emergency surgery.

Results

Of the data analysed, there was an equal proportion of male and female patients. Median age of patients was 62. Median BMI of all patients was 29 and median BMI of those developing hernias was 37. 80.8% of open cholecystectomies were elective procedures and 19.2% were emergency procedures. Infection rate was found to be 3.8%, and 30-day mortality was 1.9%. The mean rate of incisional hernia was 7.7% with mean rates of mass and layered closure at 2.7% and 11.1%, respectively. Fisher’s exact test showed that there was no statistical significance in closure method on hernia development.

Conclusions

We found no statistical significance in incisional hernia development between mass and layered closure in open cholecystectomies. No statistical significance was seen in hernia development with relation to age, gender and elective vs emergency surgery, however greater BMI was found to be statistically significant in increasing risk of hernia development. Larger, prospective multi-centre data are needed to further evaluate these results and aid surgeons in choosing an optimal closure technique in the future.
HPB P51 One hundred consecutive pancreaticoduodenectomies performed by a newly appointed consultant surgeon: perioperative clinical outcomes
Authors: Patel Bhavik , Dennison Ashley , Arshad Ali
Published: November 2023

Background

Pancreaticoduodenectomy (PD) involves surgical resection of pathology affecting the pancreas and periampullary region. PD was historically associated with high rates of morbidity and mortality. More recently there has been a reduction in 90-day mortality (2-5% in most series), however morbidity remains high. Postoperative pancreatic fistula (POPF) remains a main source of major morbidity after PD. There is conflicting data regarding POPF and morbidity rates, which may be higher for newly appointed compared to established consultants, reflecting reduced operative exposure for senior trainees. We present a consecutive series for a newly appointed consultant surgeon, with particular attention on clinical outcomes.

Methods

Between July 2018 and April 2023, 100 consecutive pancreaticoduodenectomies were performed by a single surgeon (AA). Pancreatico-jejunostomy reconstruction was performed in all cases using a 2 layer duct to mucosa technique, reproduced from a senior surgical mentor (AD) during training. A post hoc analysis of a prospectively maintained database was performed to determine outcomes of these patients. Data collected included patient demographics, neoadjuvant therapy, intraoperative details, Pancreatic Fistula Risk Scores, morbidity details, length of stay and 90-day readmission. POPF was defined according to the latest definition by the International Study Group of Pancreatic Surgery.

Results

43 patients underwent a pylorus preserving procedure whereas 57 underwent a classic PD (M:F 3:2; median age 66 (range 20–85) years; median BMI 25.4; ASA ≥ III n=38). The mean operative time was 479 minutes; mean blood loss was 719ml and mean pancreatic duct size was 4.8mm. 13 patients underwent portal vein resection. Median hospital stay was 8 days (range 5–35). Clinically significant pancreatic fistula rate was 6% (5 Grade B and 1 Grade C). 90-day mortality was zero and major morbidity (Clavien-Dindo grade ≥ III) rate was 7%. 90 day readmission rate was 6%.

Conclusions

This case series of 100 PDs by a newly appointed consultant demonstrates clinical outcomes which are comparable to more experienced established consultants in the best performing units. These outcomes can be attributed to standardisation and reproduction of operative reconstruction technique learned during training from a senior surgical mentor, meticulous post-operative care and multidisciplinary team working at a high-volume pancreatic surgery centre. Excellent clinical outcomes from PD can be achieved by new consultant surgeons, in an era of relatively diminished surgical exposure during training, by following these tenets.
HPB P52 Castleman Disease in Hepato-pancreaticobiliary Surgery: Friend or Foe?
Authors: Govindu Emeema , Florou Evangelia , Fernandez-Pujol Andrea , Shankar Sadhana , Evangelos Prassas
Published: November 2023

Background

Castleman disease is a rare lymphoproliferative disorder with low malignant potential. It is associated with risk of lymphoma & follicular dendritic cell tumours. The disease is poorly understood and is well noted in literature, the difficulty in reaching to a diagnosis. While the systemic form of the disease is a subject of Hematological work up, the unifocal disease usually consists of radiologically detected retro-peritoneal or mesenteric masses posing diagnostic challenge to hepato-pancreatico-biliary surgeons.

Methods

Over a period of 12 years, from 2011 till 2023, in our institution we have identified 4 cases of Castleman disease. Median age of is 60 yo with equal incidence in both sexes. In our series, in all four cases, the diagnosis was incidental while they were being worked up for other conditions. In fact, in 1 case the diagnosis was unexpected after surgery for other reason. Extensive work up including cross-sectional imaging studies failed to reach a diagnosis, therefore, the latter was established by excision.

Results

All four patients underwent resection that accomplished diagnosis.Three patients underwent surgery for primary excision of the tumour located in various sites of upper abdomen; one para-duodenal, one retro-hepatic and one aorto-caval. In one case, the nodule was a FDG-PET avid mesenteric mass resected in the context of planned Whipple’s procedure for cancer. The Histopathological examination confirmed diagnosis in all cases. Haematology follow-up was recommended in two cases one of which progressed to follicular dendritic cell tumor. All patients were HIV negative and HHV-8 negative. The longest follow-up is 12 years with no evidence of recurrence.

Conclusions

Castleman’s disease is a rare entity with very low malignant potential. Cases with unifocal disease in upper abdomen are referred to Hepato-pancreato-biliary surgeons and resection is the treatment of choice. The latter allows histopathological analysis establishing the diagnosis. This case series is useful to all HPB surgeons who may come across this diagnostic challenge for this poorly understood pathology.
HPB P58 Laparoscopic cholecystectomy as a training case in the post-Covid world
Authors: Hussain Muhammad , Asarbakhsh Mariam , Singh Gautam , Routledge Jamie , Wijayendran Anusan , Sowemimo Sinmidele , Saha Arin
Published: November 2023

Background

Laparoscopic cholecystectomy is an index procedure for all higher surgical trainees, regardless of sub-specialty. Minimum numbers and evidenced ‘Level 4’ competency are necessary for successful completion of training. The Covid-19 pandemic led to falls in training opportunities, during the acute phase itself and in the current drive to reduce elective waiting lists. More cases are outsourced and those cases that are being performed in the NHS may be more complex due to longer waiting times. These twin pressures have led to concerns that training opportunities for laparoscopic cholecystectomy are being limited. This study evaluated the training opportunities for laparoscopic cholecystectomy.

Methods

All patients who had laparoscopic cholecystectomy over a four-month period, from January 2023 to April 2023 were identified from a prospectively maintained database of operations. Electronic patient records were interrogated to gather pre-operative data (symptomology, co-morbidities, acuity of presentation, pre-operative investigations), intra-operative findings and progress (grade of primary surgeon, nature of operation) and post-operative outcomes and complications. Factors which were associated with the case being performed by a trainee were assessed, as well as differences in outcomes between consultant and registrar procedures.

Results

There were 150 laparoscopic cholecystectomies performed during the study period. 79 (53%) of these cases were performed acutely ('hot' gallbladders). Registrars performed 36 elective laparoscopic cholecystectomies (51%) and 42 acute cases (53%). Operating time was comparable between registrars and consultants (median operating time [registrar vs. consultant], 72 vs. 78 minutes). There were no particular pre-operative factors that predicted a case being performed by a trainee. There were no differences in post-operative outcome or complication between grade of primary surgeon; there were no bile duct injuries. There were three patients who had a return-to-theatre (2 registrar, 1 consultant case).

Conclusions

The current case mix in our hospital has meant that just over half the laparoscopic cholecystectomies performed were completed by a trainee. Not a single case was performed by an 'SHO' level surgeon, suggesting that this operation is now the preserve of higher surgical trainees. Without a high-functioning acute gallbladder service, training opportunities for this operation would be severely limited. It is safe to train laparoscopic cholecystectomy, even in the acute setting, and more should be done to identify factors which could improve training opportunities.
OGC P10 Implementation of an Oesophago-Gastric Robotic Programme in a Tertiary Centre and the Evolution to a Structured Training Programme for Career OG Trainees
Authors: Paine Heidi , Bull Alexander , Abbassi-Ghadi Nima , Singh Pritam , Madhavan Anantha , Preston Shaun R
Published: November 2023

Background

Robotic surgery affords advantages over standard laparoscopic surgery, for both patients and surgeons. Robot-assisted minimally invasive oesophagectomy (RAMIO) has demonstrated shorter operative time and improved lymph node yield (RAMIE trial). Benefits to the surgeon, and patient, include enhanced visualisation, greater precision, and improved ergonomics. During any transition to robotic surgery the need to maintain patient safety and outcomes, especially during the learning curve, is paramount. The impact on training should not be underestimated, with lost opportunities for trainees to develop procedural competence whilst on rotation. We describe the evolution of a robotic oesophago-gastric programme in a tertiary upper GI centre.

Methods

Implementation began in 2019 with online modules, simulation, and wet-lab workshops. There was external proctorship of the first two consultants for fundoplication then again for thoracic–phase robotic surgery 28 months later. Meanwhile these consultants facilitated the training of consultant colleagues to ensure a whole-team transition to robotics. This rapidly led to the introduction of component-based training of senior trainees in all abdominal aspects of robotic UGI surgery. This will ultimately progress to training career OG cancer surgeons in full RAMIO. Throughout the implementation process, regular audit allowed us to ensure that there was no adverse impact on patient outcomes.

Results

246 robotic UGI procedures were performed since September 2020, progressing step-wise from anti-reflux to RAMIO. Initially two consultants were trained, with staged introduction of two others. Subsequently, senior trainees commenced training in sequential components of procedures. Since progression to full RAMIO, the majority (82%) of two-phase oesophagectomies have been robotic. Of non-robotic, one (3%) abdominal conversion for bleeding, one planned open abdomen, and 12% due to a lack of robot access. Introduction of training of non-consultant grades in June 2022 occurred in parallel with thoracic phase training of three consultants. Trainees performed substantial components of 33/130 cases over this time.

Conclusions

We report the structured, stepwise evolution of an oesophago-gastric robotic programme in a tertiary centre up to full RAMIO with the inclusion of in-house mentoring and training of career OG trainees. Weekly robotic operating lists and high throughput of cases have facilitated uptake across all surgeons and in the majority of cases. The uptake across all consultants has facilitated relatively early on-console training of senior trainees to minimise the impact upon their career development. As an established service with full team engagement, moving forward we anticipate even greater robotic access and trainee involvement.
OGC P11 Outcomes in patients with gastric cancer and positive peritoneal washings
Authors: Andrea Cross , Phillips Alexander , Immanuel Arul , Wahed Shajahan , Hayes Nick
Published: November 2023

Background

The presence of positive cytological washings in the absence of overt peritoneal disease (P0C1) represents metastatic disease. Most centres advocate for neoadjuvant chemotherapy and full restaging including repeat laparoscopy and washings, with resection offered to those in whom restaging is negative. This approach was implemented at our institute in 2012 and when evaluated in 2015 was found to have very good results with 63% of patients resected and 90% 2-year survival.

Since this time chemotherapy regimens have changed meaning this earlier approach requires additional scrutiny.

Methods

A retrospective review of a prospectively maintained database of all upper GI cancer patients treated at the Northern Oesophago-Gastric Unit (NOGU) was undertaken. All patients with adenocarcinoma of the stomach or gastroesophageal junction without metastases on imaging and who underwent staging laparoscopy between August 2012 and August 2022 were identified. Patients who had positive cytological washings without evidence of overt peritoneal disease were included in the analysis. Data were extracted including demographics, treatment data and oncological outcomes. Survival data were collected and patterns of recurrence determined.

Results

630 patients underwent staging laparoscopy. Resectable P0C1 disease occurred in 55/630 (8.7%), and 48/55 commenced chemotherapy. Restaging occurred in 45/48 (93.8%) and 21/45 (46.7%) went on to have definitive surgery where 15/45 (33%) were resected.

Recurrence occurred in 8/15 patients, 3 of which had peritoneal metastases. Median time to recurrence was 16 months (range: 6-34). A total of 9 patients died during follow up which occurred at a median of 14 months (range: 5 to 43). Overall median survival of the cohort was 28 months (range: 5 – 111), with survival of 60% and 25% at 2 and 5 years, respectively.

Conclusions

This study demonstrated 60% 2-year survival in patients treated with curative intent who initially had positive peritoneal cytology. We were not able to demonstrate a predominate pattern of peritoneal recurrence. Furthermore, 25% of patients survived for at least 5 years after surgery, indicating that this remains an acceptable approach to the management of P0C1 disease with current best practice chemotherapy regimens.
OGC P13 CNS and Dietitian led clinical follow-up with support from a survivorship multi-disciplinary team meeting: A model of care for patients after oesophago-gastric (OG) cancer surgery
Authors: Evans Orla , Taylor Joanna , Baker Cara , Kelly Mark , Knight William , Hegarty Jane , Henggeler Cordula , Rusu Oliviana , Mundle Georgia , Gossage James , Dunn Jason , Zeki Sebastian , Davies Andrew
Published: November 2023

Background

Major upper gastro-intestinal (UGI) cancer surgery in combination with chemotherapy offers the best chance of cure for patients with oesophageal and gastric cancer. However, these treatments have significant long-term side-effects resulting in a high symptom burden in this patient group. This adversely affects quality of life and places significant demands on healthcare after surgery. There is a large variation in follow-up services nationally, with little guidance on optimal practice.

Methods

A clinical nurse specialist (CNS) and Dietitian led clinic has been utilised in this patient group for 12 years at St Thomas’ hospital, with UGI surgeon support as required. In 2021, a survivorship multi-disciplinary team meeting (MDM) consisting of CNS, Dietitian, Gastroenterologist, UGI surgeon and psychologist was introduced. This aimed to support the clinic by discussing management of complex cases.

Results

Since 2011, approximately 3000 patient consults have been undertaken in the survivorship clinic. These patients benefited from specialist follow-up, expertise in symptom management, holistic needs assessments, recurrence surveillance and specialist dietetic advice. These patients were removed from surgical and oncology out-patient clinics, creating greater capacity in these services. Patient feedback has consistently supported this model of follow-up. Complex patients are discussed in the survivorship MDM which supports the clinic.

Conclusions

CNS and Dietitian led clinics, alongside a survivorship MDM, may provide a better model of follow-up compared to traditional surgical clinics by offering a greater breadth of expertise and consistency of follow-up. Evaluation of patient centred outcomes and economic analysis, in addition to on-going national initiatives to standardise the investigation and management of symptoms following major UGI surgery, would support replicating this model in other centres.
OGC P14 Robotic-assisted Minimally Invasive Oesophagectomy using the Versius System: Initial Experience and Short Term Outcomes from a Tertiary Oesophagogastric Cancer Centre
Authors: Slim Naim , Higgs Simon , Hornby Steve , Dwerryhouse Simon
Published: November 2023

Background

Oesophagectomy is the gold standard treatment for patients with early or locally advanced oesophageal cancer. Minimally invasive approaches are associated with reduced perioperative morbidity and mortality, and whilst such methods have traditionally employed a combination of laparoscopic and thoracoscopic approaches, the use of the robot has additionally conferred a greater degree of dexterity and precision for the operating surgeon. The Versius(R) system (CMR Surgical) has a modular design comprising individual arms which offers flexibility with patient positioning. Despite its uptake, the feasibility and safety of the Versius system with minimially invasive oesophagectomy has not been characterised.

Methods

We performed a retrospective review of patients operated with curative intent for oesophageal cancer between October 2021 and March 2023. Patients who underwent robotic-assisted oesophagectomy were included in the study, including hybrid and fully robotic approaches. Data pertaining to short term post-operative and oncologic outcomes was obtained and analysed.

Results

Seventeen robotic-assisted oesophagectomies were performed. Sixteen (94.1%) underwent a hybrid approach; eight (47.1%) with laparoscopic abdomen and robotic thoracic phases, and the remainder with robotic abdomen and open thoracic phases. One (5.9%) underwent fully robotic abdominal and thoracic oesophagectomy. There were four (23.5%) unplanned conversions to thoracoscopic or laparoscopic surgery. The median operating time was 454 minutes, and length of stay was 11 days. Five patients suffered a major (Clavian-Dindo >III) compllication. There were no deaths within 90-days of sugery. The median lymph node harvest was 23.5 nodes, and a microscopically margin-negative (R0) resection was achieved in 87.5% of cases.

Conclusions

Our experience with the CMR Versius System is that of safety and feasibility, and suitability for both the abdominal and thoracic phase of minimially invasive oesophagectomy. Further studies are warranted to assess longer-term oncologic and survival outcomes.
OGC P20 A Systematic Mapping Review of Core Outcome Reporting in Surgical Research for Oesophageal Cancer
Authors: Matias Nadia , Thomson Jack , Naqvi Anie , Alkhaffaf Bilal
Published: November 2023

Background

The UK has one of the highest rates of oesophageal adenocarcinoma worldwide. Surgical resection, with peri-operative chemotherapy, is the cornerstone of curative treatment. The evidence base for which surgical approach is best (including open, hybrid, totally laparoscopic/thoracoscopic, and robotic surgery) is negatively affected by heterogeneous reporting of outcomes. This study examines the degree to which outcomes deemed critically important to patients and healthcare professionals (a core outcome set - COS) are reported by studies in this field.

Methods

We undertook a mapping review of prospective cohort studies, randomized controlled trials (RCTs), and published protocols in the field of oesophageal cancer surgery. Evidence Based Medicine Reviews, MEDLINE, EMBASE, and CINAHL were searched for relevant studies conducted over a 10-year period (2011-2021). We mapped the reporting of 10 core outcomes during this period as described by a COS for oesophagectomy trials (overall survival; in-hospital mortality; inoperability; the need for additional intervention; respiratory complications; conduit necrosis and anastomotic leak; severe nutritional problems; the ability to eat and drink; problems with acid indigestion or heartburn and overall quality of life).

Results

Initial searches identified 8944 potentially eligible records, which, after exclusion of duplicates, abstract screening and full paper reviews, yielded 57 eligible studies that recruited 10,561 patients (36 prospective cohort studies, 16 RCT’s and 5 published protocols). No study reported all core outcomes. The median number of outcomes reported was 4 (IQR 3). ‘In-hospital mortality’ (86%), ‘conduit necrosis/leak’ (81%) and ‘respiratory complications’ (79%) were reported by most studies. ‘Quality of life’ (26%), reflux symptoms’ (21%) and 'severe nutritional effects' (19%) were rarely reported alongside ‘need for reintervention’ (16%). No improvement in reporting rates was seen during the study period.

Conclusions

The reporting of core outcomes in surgical research for oesophageal cancer does not adequately reflect the priorities of patients and healthcare professionals. Further work is therefore needed to significantly improve the reporting of these core outcomes and increase the methodological quality of studies in this field. The results from this study suggest that there is a need for further high-quality prospective studies and RCTs which encompass the reporting of core outcomes.
OGC P22 The Prevalence of Malabsorption and Use of Pancreatic Enzyme Replacement Therapy Post Upper GI Surgery
Authors: Duffy Niamh
Published: November 2023

Background

Pancreatic enzyme insuffiency (PEI) appears to be under recognised and under treated in upper GI surgery due to limited evidence regarding the prevalence of PEI post operatively. This has potential to exacerbate the risk of malnutrition in an already vulnerable patient group. Pancreatic enzyme replacement therapy (PERT) may influence nutritional status and quality of life after Upper GI surgery, but the research to date remains controversial. A retrospective audit was carried out to review the use of PERT in 233 Upper GI surgeries across a two-year period.

Methods

Retrospective audit documenting all patients that have undergone a GIST resection, distal gastrectomy, subtotal gastrectomy, completion gastrectomy, oesophagectomy and total gastrectomy between 2021-2022 at a tertiary centre for Upper GI cancer surgery. It was recorded from electronic patient records which of these patients were commenced on PERT post operatively. The time frame in which the PERT was initiated was captured, as well as and what dose patients required to provide symptom relief. The duration of PERT prescription was recorded in addition to patients’ tolerance.

Results

Initiation of PERT varied from one month to one year after surgery, with most patients (n=24) commencing PERT within the first month. The final dosage of PERT required varied between 50,000iu (n=36) and 125,000iu (n=6). Many patients remain on PERT (n=53); whilst 26% of individuals stopped PERT within six months due to no benefit found or poor tolerance (n=19).

Conclusions

The use of PERT in one third of surgical Upper GI patients highlights the prevalence of PEI in this patient group. This data indicates the initiation of PERT is higher within the first three months following surgery, with the majority of these patients’ requiring PERT for long term use. A larger, multicentre trial is needed to further analyse the benefits of PERT on weight and quality of life, whilst addressing the potential influence of confounding variables such as disease stage and adjuvant treatment.
OGC P23 Modified Frailty Index is not a good predictive tool of postoperative mortality following minimally invasive oesophagectomy
Authors: Ari Kaso , Sivarajan Sri , Lee Angela , Coleman Alexandra , Kulasegaran Suheelan , Kumar Bhaskar
Published: November 2023

Background

Evaluating frailty in the elderly population is crucial in preoperative assessment to identify high-risk patients. The modified frailty index (m-FI) is known to predict postoperative mortality in various surgical populations, but its predictive value in oesophagectomy patients' long-term mortality is unclear. No studies have specifically quantified frailty and its association with long-term postoperative mortality in oesophagectomy patients. This study investigates the association between m-FI score and long-term mortality in patients undergoing minimally invasive oesophagectomy (MIO).

Methods

The m-FI is a scoring tool of 11 parameters quantifies frailty in surgical patients. Retrospective analysis (1/1/2014-31/12/2023) of patients aged ≥75 years undergoing minimally invasive oesophagectomy procedures for cancer, at a single h[ka1] igh volume tertiary referral centre was carried out. Primary outcome was defined as 1-year all-cause mortality with overall length of survival as the secondary outcome. After sensitivity analyses m-fi score of less than 1 or greater than 2 were most predictive of mortality.

Results

Ninety-one patients (mean age 78 years, age range 75-88, male to female ratio of 4:1) were included, with a median m-FI score of 1 (range: 0-5). Patients with an m-FI score of ≥2 had a higher 1-year mortality rate (30% vs. 19%, p=0.195) and shorter overall median survival time (34 months vs. 47 months, p=0.399) compared to those with a score of ≤1. After adjusting for covariates, including preoperative chemotherapy, age, sex, and cancer staging, an m-FI score of ≥2 had a hazard ratio of 1.65 (95% CI: 0.68 to 3.98, p=0.267) for 1-year mortality compared to ≤1.

Conclusions

The m-FI tool can predict post operative mortality in a range of surgical specialities. The results of our study would suggest that higher m-FI score would correlate with worse long term mortality outcomes, however at this stage the m-FI tool cannot be applied in a clinical setting to accurately define elderly patient's probable outcome following MIO. Additional multicentre data is needed to establish its true predictive value in this patient cohort.
OGC P26 Safety and efficacy of 30mm pyloric balloon dilatation after esophagectomy for treatment of delayed gastric emptying
Authors: Abdelrahman Mohamed , Ariyarathenam Arun , Berrisford Richard , Humphreys Lee , Sanders Grant , Chung Tham Ji , Wheatly Tim , Chan David
Published: November 2023

Background

Delayed gastric emptying (DGE) affects up to 37% of patients after esophagectomy and is treated with dilatation of the pylorus with either a 20mm or 30mm balloon. Although pyloric balloon dilatation (PBD) with the 20mm balloon is safe, it may not be as effective as the 30mm balloon. The aim of this study was to assess the safety and efficacy of PBD with a 30mm balloon in the acute setting.

Methods

Details of consecutive patients who underwent esophagectomy for cancer and diagnosed with DGE and underwent PBD between April 2014 to July 2021 were analysed retrospectively from a prospectively maintained database. The main outcome measures were rates of re-dilatation and morbidity.

Results

Out of 584 patients who underwent esophagectomy, 106 patients [71 Male (67.7%), median age (range) 68 (38-81 years)] were diagnosed with DGE (18.2%). Seventeen patients (16%) were treated conservatively. Six patients (5.7%) underwent intra-operative pyloroplasty. A total of 83 patients (78%) underwent PBD. Seventy-one patients (67%) underwent PBD with a 30mm balloon) on the index admission at a median of 9 days (range 2 – 27 days) post-operatively. Two patients (2.8%) developed leaks post dilatation. Patients were discharged home after a median (range) of 4 (1-91) days after PBD. Total length of stay was a median (range) of 13 days (7-119).

Conclusions

Pyloric balloon dilatation with a 30mm balloon is a safe and effective treatment option for delayed gastric emptying after esophagectomy in the index admission.
OGC P31 On the role of Cytosponge for Barrett’s surveillance: assessment of viability and safety of this new technology
Authors: Asarbakhsh Mariam , Singh Gautam , Megson Tyler , McDonald Claire , Olejnik Hannah , Verma Harsh , Saha Arin
Published: November 2023

Background

Barrett’s Oesophagus is a pre-malignant change where the normal stratified squamous epithelium is replaced by intestinal columnar epithelium. Current guidance produced by the British Society of Gastroenterologists describes 'gold-standard' surveillance as regular upper GI endoscopy with quadrantic biopsies for every 2cm length of Barrett’s oesophagus. The Covid pandemic led to significant delays in the Barrett's surveillance; as a result, many patients have fallen outside their maximum recommended surveillance interval. Cytosponge is a novel cytology sampling device which has a potential role in Barrett's surveillance though its use for this condition remains controversial.

Methods

All patients who were due for Barrett's surveillance in 2022 were identified and screened for suitability for Cytosponge, instead of endoscopy. Patients who were ineligible, or who declined Cytosponge, were sent for endoscopy. The remaining patients underwent a Cytosponge procedure as their primary Barrett's surveillance modality. Early clinical outcomes, patient satisfaction and cytology results were recorded. All patients have been followed up to determine if they have subsequently required endoscopy or had an early diagnosis of oesphago-gastric cancer.

Results

193 patients (77%) were suitable for the Cytosponge test. 175 (90%) did not require endoscopy after Cytosponge. 18 patients (10%) had urgent endoscopy after Cytosponge; 9 patients had atypia on cytological analysis, 3 had aberrant p53 and 4 had dysplasia. Three patients had inadequate cytology. 2 of the patients with dysplasia had high-grade dysplasia confirmed on endoscopy; these were successfully treated with radiofrequency ablation. Median follow-up was 14 months (range, 10-22). No patients have been diagnosed with oesophago-gastric cancer so far; 8 patients (4%) were referred later for anaemia or weight loss. None of these patients had oesophago-gastric cancer.

Conclusions

These data suggest that Cytosponge can be a valuable first-line tool in surveillance of Barrett’s Oesophagus. Cytology results identified specific patients who required urgent endoscopy. No patients have had an early diagnosis of dysplasia or malignancy after a Cytosponge that was normal or showed intestinal metaplasia alone. Our findings suggest that Cytosponge should be integrated as an adjunct in Barrett’s surveillance, with clear benefits in safer and accurate monitoring of the condition without the risks of endoscopy.
OGC P34 Oesophageal and Gastro-oesophageal junctional cancer recurrence post hybrid and minimally invasive oesophagectomies
Authors: Muir Duncan , Ash Stephen , Sgromo Bruno
Published: November 2023

Background

Minimally invasive oesophagectomy (MIO) has shown favourable short-term outcomes compared to the open and hybrid alternative, with similar oncological resection rates and mortality. Despite this, there is limited literature on recurrence patterns between operative approaches, with little reported comparing hybrid and minimally invasive oesopahgectomies. This study aimed to evaluate the differences in recurrence patterns between hybrid and totally minimally invasive oesophagectomies.

Methods

All patients undergoing an Ivor-Lewis oeosphagectomy via a hybrid (HILO) or totally minimally invasive approach were included. Patients received clinical and radiological follow-up with CT chest, abdomen and pelvis at regular intervals or in the presence of concerning symptoms.

Propensity matching was performed and matched cohorts were analysed. Statistical analysis was performed using R 4.1.2

Results

Forty HILO and 56 MIO patients were included. Overall recurrence was reduced in MIO (50% HILO vs 21% MIO p=0.003, 50% HILO vs 25% MIO, p=0.02 after matching). Distant recurrence was higher in HILO (45% HILO vs 20% MIO p=0.002, 45% HILO vs 23% MIO p=0.02 after matching). For GOJ cancers, there was reduced overall recurrence in MIO compared to HILO (52% HILO vs 9% MIO, p=0.002 overall, 24% hybrid vs 0% MIO, p=0.01 for local recurrence). These differences remained after propensity matching (52% hybrid vs 14% MIO, p=0.02 overall, 24% HILO vs 0% MIO, p=0.046 for locoregional).

Conclusions

MIO patients showed reduced overall and distant recurrence compared to the hybrid technique, with also reduced locoregional recurrence in an unmatched comparison. Reduced overall and local recurrence was seen in MIO cases for cancer of the GOJ. Resection rates and major complication rate was similar between the modalities. For future studies, an agreed definition on locoregional recurrence would be beneficial, as would a reached consensus on lymphadectomy in oesophagectomy.
OGC P36 The role of self-expanding metallic stents and surgical gastric bypass for palliation of gastric outlet obstruction caused by gastric cancer
Authors: Digby Maria , Doran Sophie , Lee Fred , Hersey Naomi , Tamhankar Anand
Published: November 2023

Background

The treatment of inoperable gastric cancer, causing gastric outlet obstruction (GOO) is focused on palliation of symptoms. Self-expanding metallic stent (SEMS) or surgical gastric bypass (SGB) are used to relieve GOO. Available data on SEMS and SGB are often unreliable as studies usually include patients with different causes of GOO including pancreatic or duodenal cancers or extrinsic disease. Their utility for GOO due to gastric cancer remains uncertain as gastric motility and function could be affected by the pathology. We aim to review outcomes of SEMS and SGB for GOO from gastric cancer in our unit over a 5-year period.

Methods

Retrospective review of all patients who have had SEMS or SGB for palliation of GOO from gastric cancer between 01/01/2018 and 31/12/2022. Data was collected on the pathology of the tumour, pre-intervention symptoms scoring, post-intervention symptoms scoring, length of stay, complications and survival. Thirty-five patients were identified and included in the study.

Results

Thirty patients with SEMS and five patients with SGB were analysed. Median survival was 16 weeks. Median length of stay after SEMS was 5.5 days (IQR: 1.2-12.7, range 1-83) and after SGB was 10 days (IQR: 9-11, range 8-32). 2/30 in the SEMS group had early complication requiring re-stenting and 1/5 in SGB group had early complication requiring further surgery and subsequent SEMS. Complete palliation of obstruction was achieved in 17/21 (70%) of SEMS and 4/9 (40%) of SGB patients. Complete palliation with SEMS was more likely when stomach cancer was localised (81%) rather than widespread (44%).

Conclusions

Self-expanding metallic stents are safe and effective in the palliation of symptoms in patients with gastric outlet obstruction due to gastric cancer and perhaps function better than surgical bypass. They are more effective when the obstructing gastric cancer is localised disease. Longer hospital stay associated with surgical bypass may compromise the palliative process when the survival is often limited.
OGC P41 Presentation, Management and Outcomes in Young Patients Diagnosed with Oesophageal Cancer
Authors: Smith Ossian , Alkhaffaf Bilal
Published: November 2023

Background

Oesophageal cancer is a devastating malignancy associated with poor prognosis, primarily affecting older individuals with multiple co-morbidities. However, outcomes of younger patients have been perceived as poor due to late diagnosis and more aggressive disease subtype. This subset of patients poses unique clinical challenges and requires a better understanding of their outcomes. This comprehensive retrospective cohort study aimed to evaluate the patient characteristics, treatment modalities, and survival outcomes of young patients diagnosed with oesophageal cancer, to provide further insights into this understudied population.

Methods

A retrospective analysis was conducted using electronic medical records from a regional oesophago-gastric cancer service serving 3.5 million people across the North West of England, encompassing a 5-year period between January 2018 and December 2022 inclusive. Young patients were defined as being 50 or younger at the time of diagnosis of oesophageal cancer. Clinical and pathological data, including tumour characteristics, treatment approaches, and survival outcomes, were collected. Survival analysis was performed utilising Kaplan-Meier estimates, and survival rates following oesophagectomy were compared to publicly available outcomes.

Results

87/2485 (3.5%) of patients studied were aged 50 or below at the time of diagnosis. Mean age at diagnosis was 44.3 (range = 24-50); 71% were male. Adenocarcinoma and SCC accounted for 73% (33% poorly differentiated, 40% moderately differentiated) and 25% of cases respectively. The majority presented with c-stage III (24%), c-stage IVa (17%) and c-stage IVb (46%) disease. Initial treatment intent was curative in 43%. 1-and 3-year overall survival rates were 49% and 21% respectively - similar to the wider population. 1- and 3-year survival rates after oesophagectomy were 80% and 44.5% (versus 82.5% and 59.5% for wider population).

Conclusions

Our findings underscore the concerns about the proportion of advanced-stage diagnosis in young patients with oesophageal cancer, and poorer longer-term outcomes after curative resection. This highlights the importance of timely detection and appropriate treatment strategies in this patient group. Future research should focus on understanding the underlying mechanisms in this group, exploring novel therapeutic strategies as well as validating these finding in larger and more diverse patient populations.
OGC P42 Presentation, Management and Outcomes in Young Patients Diagnosed with Gastric Cancer
Authors: Smith Ossian , Alkhaffaf Bilal
Published: November 2023

Background

Gastric cancer poses a significant global health challenge, mainly affecting older individuals with well-established risk factors. However, outcomes in young patients have been perceived as poorer due to late diagnosis and more aggressive disease subtype. There are also a small sub-set of younger patients in which gastric cancer is genetically inherited. This comprehensive retrospective cohort study aimed to evaluate the patient characteristics, treatment modalities, and survival outcomes of young patients diagnosed with gastric cancer, to provide valuable insights into optimal therapeutic strategies.

Methods

A retrospective analysis was conducted using electronic medical records from a regional oesophago-gastric cancer service serving 3.5 million people across the North West of England, encompassing a 5-year period between January 2018 and December 2022 inclusive. Young patients were defined as being 50 or younger (eligible for genetic testing) at the time of diagnosis of gastric cancer. Clinical and pathological data, including tumour characteristics, treatment approaches, and survival outcomes, were collected. Survival analysis was performed utilising Kaplan-Meier estimates, and survival rates following gastrectomy were compared to publicly available outcomes.

Results

60/956 (6.3%) patients were aged 50 or below at the time of diagnosis. Mean age was 42.1 (range = 28-50); 48% were male. Stages III and IV of disease were observed in 27% and 57% of patients respectively. Poorly differentiated disease was observed in 53%, with HER-2 positivity in 13%. Distal gastric cancer represented 56% of cases and proximal cancer 27%. Initial treatment intent was curative in 43%. 1-year and 3-year overall survival was 51% and 33. 3-year overall survival was 92% for 20 patients who received gastrectomy versus 60% in all patients reported by NOGCA.

Conclusions

This study suggests that young patients with gastric cancer present with significantly advanced disease. Despite this, young patients show similar medium- and long-term survival rates. Well selected young patients can be offered treatment with curative intent with good medium- to long-term outcomes. Future research should focus on understanding the underlying mechanisms in this group, exploring novel therapeutic strategies, including the role of genetic testing, as well as validating these finding in larger and more diverse patient populations.