bluuebunny/crossref_metadata_2025 huggingface dataset:
OGBN P32 Outcomes of patient with Biliary Dyskinesia undergoing laparoscopic cholecystectomy - A multicentre cohort study
Authors: Ali Kiren , Shahzad Khan Khurram
Published: November 2023

Background

Biliary dyskinesia (BD) is a benign disorder characterized by recurrent episodes of biliary pain in the absence of gallstones on ultrasound, normal liver function tests and an ejection fraction (EF) of <35% on hepatobiliary iminodiacetic acid (HIDA) scan. Laparoscopic cholecystectomy (LC) remains the only known effective treatment for BD. However, many surgeons are reluctant to offer LC in such patients due to the fear of non-resolution of symptoms. Our aim was to analyse the outcome of patients who underwent LC for BD in terms of resolution of the biliary symptoms.

Methods

Multicentre retrospective cohort study of patients who have BD proven on HIDA scan from January 2015 to December 2022. BD was defined as EF ≤35% on HIDA scan. Those with EF ≤35% but had evidence of gallstones, microlithiasis or post op leak were excluded from the study.

Electronic case notes were reviewed for demographic details, duration of symptoms, body mass index (BMI), liver function test (LFT), radiological investigations, endoscopy report and histopathology results of cholecystectomy. Rome IV criteria of functional gastrointestinal (GI) disorders was used to confirm symptoms were biliary in origin.

Results

Of the 222 patients who had HIDA scan, 35 (15.7%) patients had BD. 26 (74.2%) were female and median age was 42 years (IQR 33-55). Median time from the onset of symptoms and HIDA scan was 18 months.

19 (54.2%) patients had LC preformed, 9 (25.7%) were discharged with decision of LC not required, 4 (11.4 %) had no further review and 2 (5.7%) still having LC under consideration. Histopathology of LC was, chronic inflammation in 10 (52.6%), cholesterosis in 3 (15.8%) and 4 (20.1%) had normal gallbladder. 13 (68.4%) patients who underwent LC were symptom free 12 months post-surgery.

Conclusions

BD although painful and potentially lifestyle limiting, does not progress to more serious consequences if untreated. Diagnosis is usually difficult, and patients go through extensive investigations before they have HIDA scan. LC improves the symptoms in two thirds of patients and should be offered to all patients with BD with appropriate counselling.
OGBN P33 The Missing LINX® - Reconstituting the Hill Valve
Authors: Clements Caterina , Bezzaa Sabrina , Dunstan Matthew , Stroud Lauren , Nehra Dhiren
Published: November 2023

Background

Magnetic sphincter augmentation (MSA) with LINX® is an increasingly utilised procedure as an effective and safe alternative for fundoplication in the management of gastro oesophageal reflux disease (GORD). Our aim was to evaluate the post-operative LINX® endoscopic appearances in maintaining the competence of the Hills valve. Here we present a retrospective review of endoscopic assessment post insertion of LINX® Reflux Management System.

Methods

Patients who underwent magnetic sphincter augmentation with LINX® between December 2012 and December 2022 at a single district general hospital were recruited for a retrospective case analysis. Photographs taken at the time of endoscopy were assessed to evaluate the gastroesophageal flap valve using the Hill classification.

Results

Of 186 patients who underwent MSA, 40 underwent endoscopy post-operatively and of these 35 had photographs suitable for evaluation. There were various indications for endoscopy including dysphagia (13), dyspepsia (9), abdominal pain (7), laryngopharyngeal reflux (2), odynophagia (2), Barrett’s surveillance (1) and food bolus (1). Median time from LINX® to endoscopy was 2.5 years. 33 out of 35 patients (94.2%) were found to have Hills Grade I. One patient (2.8%) had Hills Grade II and one patient (2.8%) had a recurrence of their hiatus hernia, Hills Grade IV.

Conclusions

Endoscopy is a useful modality to assess symptomatic patients after MSA with LINX®. This study has confirmed reconstitution of the Hills valve on endoscopic assessment in 94.2% of patients. This supports LINX® as an effective and robust solution in the management of GORD.
OGBN P37 Improving the Accuracy of Endoscopic Measurements of the Size of Gastrointestinal Lesions by a Guidewire Scale
Authors: Talalak Nanthawat , Orrapin Saritphat , Wattanarochanaporn Sittichock , Sotananan Teerawat , Likidkarnchanakornkij Thanakorn , Mahawongkajit Prasit
Published: November 2023

Background

Endoscopic measurement of lesion size is important for the assessment of the healing process, treatment strategies, and cancer staging. Consequently, accurate measurement of the size of the lesion is critical for proper candidate selection for endoscopic resection of early gastric cancer. A visual estimation of the size of the lesion has been widely used, but inaccuracy has been found. Hence, several endoscopic measurement methods have been proposed, but no reliable method has been used thus far. Therefore, we developed a guidewire scale for measuring the size of the lesion. This study focused on improving the accuracy on a practical level.

Methods

The guidewire scale consisted of green and yellow bands alternating on the wire, which were 5 mm for each band and a total of 30 mm in length. To assess the procedure’s validity and reliability, endoscopists estimated the size of the artificial lesions in the model by visually comparing them with the guidewire measurements. We found measurement error of the guidewire by 0.036±0.25 mm. The endoscopists determined the size of the lesion by the guidewire scale and used a numeral rating scale (NRS) to assess the satisfaction after the procedure.        

Results

We enrolled 52 patients who were evaluated for the size of the lesion by the guidewire scale. The rate of completion of the procedure was 100% without any complications. Overall, the endoscopists’ satisfaction was good (NRS ≥ 8), but satisfaction was significantly higher in the dyspepsia group (P = 0.03). The mean of the size of the lesion was 10.7±8.9 mm, and small ulcer size (size ≤ 1 cm) displayed more satisfaction. The average time of measuring the lesion was 39.4±13.6 seconds, and the procedure time ≤ 30 seconds was highly satisfactory.

Conclusions

Our guidewire scale enhanced the accuracy of the endoscopic measurement of the size of the lesion. Thus, this guidewire scale could be used to estimate the sizes easily and safely in a clinical study.
OGBN P40 Laparoscopic Cholecystectomy waiting list: morbidities and cost
Authors: Salih Ahmed K A , Tayo Oluwasegun , Jiwani Zaneen , Elnagar Mohamed
Published: November 2023

Background

Gallstone Disease refers to the presence of stones in the gallbladder or common bile duct, which can lead to symptoms and complications. Around 15% of adults are affected by this condition, but only 20% of them experience symptoms. The severity of symptoms can range from mild and nonspecific to intense pain and complications. Treatment options vary and can include conservative or medical approaches, endoscopic procedures, or surgical interventions. Cholecystectomy is considered the gold standard for managing symptomatic gallstones. In the UK, Approximately 66,660 surgeries conducted annually in the UK (61,220 laparoscopically), which cost around £111.6 million per year.

Methods

A retrospective analysis was conducted on the patients listed for Laparoscopic Cholecystectomy in the General Surgery department of Aberdeen Royal Infirmary. The study covered the period from January 1, 2019, to June 30, 2022, focusing on the occurrence of morbidities or complications, such as re-admissions and visits to the emergency department (ED), as well as the associated costs. Trakcare documentation was utilized for data collection. The data was collected in November 2022. The analysis involved identifying patients and their demographics from the Master Waitlist. Complications, hospital readmissions, and emergency surgeries were analyzed using SPSS.

Results

Out of 857 patients on the waitlist, the average age was 54.8 years, with females comprising 69.2%. The mean wait time was 15.8 months (maximum: 45 months). Around 8.2% re-presented to the ED, mostly due to biliary colic, with a mean of 3.7 visits (maximum: 8). SAC clinic visits were needed for 4.8% of patients. Hospital readmission occurred for 4.3% with an average stay of 17 days. Complications affected 11.4% of patients, including colic, cholecystitis, Choledocolithiasis, pancreatitis, Cholangitis, perforated gallbladder, Mirrizi Syndrome, and Fistula. Interventions were required for 7.2% of patients. Only 7% underwent cholecystectomy, with 8 being emergency cases.

Conclusions

The prevalence of gallstone disease is high, and patients who experience a delay in their surgical operation often suffer from various morbidities. These complications not only impact the well-being of the individuals but also create a financial burden for healthcare providers. To address this issue, the implementation of an urgent or hot Gallbladder list could potentially offer a solution. By prioritizing patients requiring immediate attention, this approach aims to reduce the adverse effects associated with prolonged waiting times and improve both patient outcomes and the overall efficiency of the healthcare system.
OGBN P43 Mucosal injury following Laparoscopic Heller’s Cardio myotomy: Experience at a tertiary referral centre
Authors: Khan Rehan , Rajendran Ilayaraja , Shetty Vinutha , Ahmed Salman , Paul Turner , Singh Mohan , Date Ravindra
Published: November 2023

Background

Heller’s cardio myotomy is a standard surgical procedure to treat patients with Achalasia Cardia. Mucosal injury is the most common serious complication of this procedure. The study was carried out to assess the impact of this serious complication on the patients who had surgery performed in this trust.

Methods

All patients who underwent Laparoscopic or Laparoscopic converted to open Heller’s myotomy for Achalasia Cardia mentioned in Flex Prod online patient record software were included in the study. Data of 57 patients who underwent the procedure was collected prospectively and analysed retrospectively.

Results

The data of total 57 patients was analysed for mucosal injuries in the perioperative period. 2 out of 3 patients suffered mucosal injuries were identified intraoperatively, subjected to laparoscopic converted to open exploratory laparotomy and repair. Both these patients recovered and were discharged home. Third patient presented day 6 postoperative period with symptoms of mucosal injury was subjected to laparotomy with repair of perforation over T-tube, had a prolonged admission and recovery leading to significant morbidity.

Conclusions

Iatrogenic mucosal perforation is the most important potentially serious perioperative complication of Hellers myotomy which can be avoided with careful and meticulous dissection. This procedure should ideally be performed at tertiary care centre where high volume of such cases is expected. Early intraoperative identification is key to good postoperative outcomes with late detection in postoperative period could lead to serious morbidities.
OGBN P44 Does laparoscopic fundoplication have a role in non-erosive reflux disease?
Authors: Halliday Laura , Donald Neil , Dighe Shwetal
Published: November 2023

Background

Non-erosive reflux disease (NERD) is a sub-group of gastro-oesophageal reflux disease (GORD) characterised by reflux related symptoms without endoscopic evidence of oesophageal mucosal erosion. Management can be challenging as the prevalence of functional dyspepsia and IBS-related symptoms is often high. This study was undertaken to examine symptom control after laparoscopic fundoplication in patients with NERD compared to those with oesophagitis associated GORD.

Methods

Patients who underwent laparoscopic fundoplication for NERD or GORD with oesophagitis between January 2017 and January 2022 were included in this study. Patients were asked to score their current symptoms using the modified DeMeester Clinical Symptom Score (CSS) and Gastrointestinal Symptom Rating Scale (GSRS), and then rate their satisfaction with the procedure.

Results

14 patients who underwent surgery for NERD and 31 with oesophagitis associated GORD were included in this study, with a mean follow up of 3.4 years and 2.7 years respectively after surgery. 86% of NERD patients and 94% of oesophagitis patients reported an improvement in symptoms after surgery. There was a trend for higher symptom scores in NERD patients (NERD patients CSS 4.57±1.95, oesophagitis patients CSS 3.45±1.79, p=0.065; NERD patients GSRS 1.99±0.37, oesophagitis patients GSRS 1.72±0.49, p=0.069). NERD patients with higher pre-operative DeMeester scores from pH testing had lower GSRS scores (r=-0.616, p=0.043).

Conclusions

With careful patient selection and detailed pre-operative counselling, surgery can play a role in the management of NERD patients. Whilst post-operative symptom control may not be as good as that achieved with classical oesophagitis associated GORD, these findings suggest that NERD patients do achieve symptom improvement after laparoscopic fundoplication. Further research is needed to help identify other factors that predict response to surgery in NERD to optimise patient selection and improve shared decision making.
OGBN P46 Megaoesophagus in a patient with achalasia treated with laparoscopic Heller cardiomyotomy
Authors: Abu Suleiman Amro , James Daniel , Wilkins Alex , Lo Terrence
Published: November 2023

Background

Achalasia is an oesophageal motility disorder that is a rare but important differential diagnosis in patients with dysphagia. Surgical treatment with laparoscopic Heller myotomy (LHM) and fundoplication is the gold standard; other options include peroral endoscopic myotomy (POEM), dilatation in cases that are unsuitable for surgery, and esophagectomy as a last resort.

Methods

We describe a case reported at our institution and the relevant workup, findings and management.

Results

A 41-year-old woman presented with persistent cough and shortness of breath on exertion. Chest x-ray showed right basal consolidation and a dense structure along the right mediastinum. CT revealed megaoesophagus with an oesophageal diameter of 7cm. Detailed history revealed long-standing history of progressive dysphagia and acid reflux and more recent history of weight loss, retrosternal pain and shortness of breath when eating solid foods. Workup included gastroscopy, oesophageal manometry and Chagas disease testing due to potential exposure to T. cruzi. A diagnosis of idiopathic achalasia was made, and she underwent laparoscopic Heller’s cardiomyotomy and Dor fundoplication.

Conclusions

Achalasia is an important differential in patients presenting with symptoms of dysphagia. This case reveals an atypical presentation of the disorder, suggesting a need to consider it in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis prior to oesophageal failure when it is still possible to intervene effectively.
OGBN P47 Isolated Pneumoperitoneum following ERCP
Authors: Bandyopadhyay Samik , Fadipe Adetokunbo , Satyadas Thomas
Published: November 2023

Background

An 84-year-old man underwent a difficult ERCP following biliary leak after laparoscopic converted to open cholecystectomy for acute cholecystitis. Postoperative scan was suggestive of bile leak from Cystic Duct stump and an ERCP-stenting had been requested to treat the problem. He needed urgent decompression for extensive pneumoperitoneum causing acute ventilatory dysfunction during the procedure. Post procedure CT showed pneumoperitoneum and pneumobilia suggesting air leak through Cystic Duct Stump.

Methods

The patient had been admitted for acute cholecystitis and had undergone treatment as an inpatient. An urgent abdominal decompression with a Veress needle after completing the procedure had resolved the acute respiratory distress. He needed a short stay in the intensive care after the ERCP before being safely stepped down to the wards. Records of the rare event was collected retrospectively from the hospital electronic patient record system.

Results

The patient recovered after continued monitoring and support in the Intensive Care. He needed transient respiratory support and treatment for lung collapse. The CT scan ruled out any duodenal injury - the initial suspected reason for the acute deterioration. The presumed cause of the pneumoperitoneum was air leak from an open Cystic Duct stump following canulation of the common bile duct.

Conclusions

Pneumoperitoneum after ERCP is usually secondary to duodenal injury. Our patient had no evidence of Free pneumoperitoneum causing respiratory compromise at ERCP - this is extremely rare. The patient was monitored till discharge for any sign of hollow viscus re-perforation Pneumoperitoneum due to air leak from Cystic Duct stump has not been reported before.
OGBN P48 Comparison of Acute Pancreatitis Management: Local Hospital Policy versus Current Practice
Authors: Alwani Omneya , Moti Terngu , Baltatzis Minas , Alasmar Mohamed
Published: November 2023

Background

This study aims to compare acute pancreatitis management between our current practice in NHS hospital in the northwest and the local hospital policy, which combines national and international guidelines in Emergency Department settings and acute surgical admissions.

Methods

In this retrospective study, we analysed data from fifty-three patients. The study focused on assessing the usage of diagnostic criteria, severity scoring, and investigations, evaluating whether they were performed or ordered. Data were collected from medical records covering the period from October 2022 to March 2023.

Results

Among 53 acute pancreatitis patients, 27 (50.9%) were male, 26 (49.1%) were female, with a mean age of 52.72 years. Gallstones were the leading aetiology in 29 (54.7%) patients. Clinical pancreatitis was diagnosed in 34 (64.2%), Only 12 (22.6%) had documented severity scoring. Amylase and lactate tests were conducted in 37 (69.8%) and 35 (66%) of cases, respectively. 15 (28.3%) had an erect X-ray, and 22 (41.5%) had an abdominal ultrasound. CT scans were performed in 42 (79.2%), Antibiotics were administered in 8 (15.1%) for suspected other pathology.

Conclusions

The study underscores the importance of standardized protocols and guidelines to optimize patient care and resource utilization. In the Emergency Department, necessary laboratory investigations like lactate and amylase tests for suspected pancreatitis are crucial. Severity scoring aids in accurate patient care assessment. Additionally, optimizing the usage of Erect X-ray and CT scans enhances diagnosis and management. Addressing these areas improves healthcare outcomes and resource allocation.
OGBN V02 Robotic common bile duct clearance
Authors: Stefanova Irena , Pencavel Timothy , Lahiri Rajiv
Published: November 2023

Background

A 44-yar old male patient presented with painful obstructive jaundice and bilirubin of 127 μmol/L. A Contrast Enhanced Computed Tomography (CECT) revealed dilated biliary tree as a result of obstructing stone in the proximal common bile duct (CBD). The patient underwent an Endoscopic Retrograde CholangioPancreatography (ERCP) and sphincterotomy which demonstrated pus in the bile duct, but also a stone impacted in the common hepatic duct which could not be extracted endoscopically. Therefore, a 7Fr pigtail stent was inserted. Subsequently, he was discharged home and re-admitted for an elective robotic cholecystectomy and bile duct clearance 6 weeks later.

Methods

Robotic CBD clearance was performed using DaVinciXi system, a 12mm Airseal and four 8mm robotic ports. The patient was supine with split legs(15 degrees), in reverse Trendelenburg position and left tilt. The CBD was dissected out, the anterior duct wall was delineated and longitudinal choledochotomy was carried out. A large stone was extracted through the choledochotomy site followed by removal of stent. Subsequently, a cholangioscopy was performed using a single-use flexible ureteroscope and no further stone disease was identified proximally or distally. Following this, a bile duct closure was performed using 4-0 Polydioxanone interrupted sutures and SutureCut Needle Driver.

Results

There were no intra- or post-operative complications. The patient made an excellent recovery from robotic common bile duct clearance and was discharged home less than 24 hours post procedure.

Conclusions

This video presentation highlights the technical aspects of robotic common bile duct clearance and demonstrates that the robotic system allows for accurate dissection and precise suturing which could reduce the risk of bile duct stricture.
OGBN V03 Robotic choledochoduodenostomy for benign common bile duct stricture
Authors: Stefanova Irena , Iosif Evangelia , Pencavel Timothy , Lahiri Rajiv
Published: November 2023

Background

A 54-year-old male patient was referred with benign distal common bile duct (CBD) stricture secondary to chronic pancreatitis. He had multiple admissions with recurrent cholangitis requiring numerous Endoscopic Retrograde CholangioPancreatographies (ERCPs) and stent exchanges including SpyGlass procedure which did not demonstrate evidence of malignancy. His quality of life was poor due to debilitating pain and recurrent hospital admissions so he was offered elective choldechoduodenostomy aiming to bypass the bile duct stricture, but also allowing continued endoscopic surveillance.

Methods

A robotic choledochoduodenostomy was performed using the DaVinciXi system, a 12mm Airseal and four 8mm robotic ports. The patient was supine with split legs(15degrees) in reverse Trendelenburg position with a slight left tilt. Initially, robotic cholecystectomy was carried out following which the CBD was dissected and its anterior wall delineated. The duodenum was kocherised to allow sufficient mobility for anastomosis. Subsequently, a longitudinal choledochotomy was performed and a metal stent was extracted. Then, an enterotomy was made perpendicularly to the choledochotomy. A choledochoduodenostomy was performed using continuous 4-0-V-Loc sutures for posterior wall and 4-0-PDS continuous sutures for anterior wall.

Results

The post-operative period was uncomplicated. The patient experienced minimal pain after procedure and was discharged home on post-operative day 2. He was reviewed in outpatient clinic 6 weeks after, and reported he had successfully discontinued all regular opiates and benzodiazepines previously used for pain control.

Conclusions

A robotic choledochoduodenostomy is an excellent alternative for the treatment of benign bile duct strictures in patients with recurrent cholangitis requiring repeated stent exchanges. Moreover, it has the advantage of continued endoscopic surveillance which is not possible with traditional hepatico-jejunostomy.
HPB P05 PET-CT in the staging of potentially resectable pancreatic cancer
Authors: Al Saoudi Tareq , Chawla Kanika , Sarwar Dawud , Isherwood John , Bhardwaj Neil , Dennison Ashley , Garcea Giuseppe
Published: November 2023

Background

Pancreatic adenocarcinoma (PDAC) presents a significant global health challenge particularly as it is generally diagnosed at an advanced stage. Although cross-sectional imaging techniques including multidetector CT (MDCT) are familiar and ubiquitously used the role and value of PET-CT scans in PDAC management remains unclear.

Methods

This six-year study analysed patients who underwent PET-CT scans for suspected PDAC. Demographics, cross-sectional imaging and PET-CT results, management decisions, and histology were collected together with rates of operation with curative intent and the time interval between scans and surgical intervention.

Results

Of 161 patients, 110 were operable, but 51 weren't. Among operable ones, 20 had extra-pancreatic lesions; 90 didn't. Without extra-pancreatic lesions, 68 underwent surgery, 12 unfit, and 10 had benign conditions. Among those explored, 9 had unconfirmed suspected metastasis. Of all explored, 48 had successful resection; 20 had precluding diseases. In the subset with extra-pancreatic lesions, 4 were inoperable due to confirmed metastasis. The remaining 16 explored had equivocal or unrelated lesions; 9 were resectable, 7 weren't. PET-CT scans impacted patient management in 8% of cases.

Conclusions

PET-CT scans play a crucial role in the management of suspected PDAC, but routine use may not be justified. Further research is needed to identify the subset of patients who benefit most. Clear guidelines for PET scan utilization in clinical practice are required to optimize the role in PDAC management.
HPB P10 The impact of an electronic referral system for tertiary pancreatitis referrals
Authors: Huntly Benjamin , Kerrison Hannah , Smith Andrew , Pathak Samir , Young Alistair , Shapey Iestyn , Pine James
Published: November 2023

Background

In the Leeds catchment, pancreatitis referrals were made ad hoc via telephone or email. This was frequently by a junior team member and essential information was frequently absent. Frustratingly the referring teams did not know who to contact and often had to make multiple calls. There was no record of these referrals and the advice provided. As a Quality Improvement we instituted an electronic referral system.

Methods

An Electronic referral system (Patient Pass, already within the Trust) was utilised. We developed a simple questionnaire for the referrer to complete. This was accessed via a hyperlink on the Leeds Pancreas Unit website. Images could be reviewed using a regional El Xero server without the need for image transfer This was implemented in September 2021.

The system is monitored Monday to Friday by either an Advanced Clinical Practitioner or by the senior registrar/fellow. Information and scans are reviewed, and all cases discussed with the on call pancreas consultant. A survey was sent to all users in secondary care.

Results

166 referrals in 21 months , Average response time from initial referral was under 3 hours. 46/166 transferred to LTHT. Average number of responses per individual referral. Overall satisfaction was over 80% from secondary care. The Pancreas team has found it easier to provide timely accurate advice on a complete set of data, especially the immediate access to images.

Conclusions

An electronic referral system has led to increased satisfaction for referrers. The system has led to an open, auditable, visible, referral and advice process. This has allowed patients to remain in the local hospital closer to home and visitors until the time intervention is needed or appropriate.
HPB P12 Do Chemotherapy Factors or Treatment Intervals Influence Pathological Tumour Response during Neoadjuvant Chemotherapy for Pancreatic Ductal Adenocarcinoma? A Bi-Institutional Study
Authors: Halle-Smith James , Leung Prudence , Hall Lewis , Askin Merve , van Laarhoven Stijn , Skipworth James , Brown Rachel , Roberts Keith
Published: November 2023

Background

Pathological response of pancreatic ductal adenocarcinoma (PDAC) to neoadjuvant chemotherapy (NAT) can be assessed using grading systems such as the College of American Pathologists (CAP) system, with favourable regression being associated with improved oncological outcomes. The aim of the study was to investigate factors associated with favourable tumour regression in patients undergoing pancreatoduodenectomy (PD) for PDAC.

Methods

Patients who received NAT before undergoing PDAC resection at two institutions in the United Kingdom between 2013 and 2021 were reviewed. Interactions between chemotherapy regimens, tumour staging, carbohydrate antigen 19-9 (Ca19-9) levels, perioperative factors and tumour regression grading (TRG) were explored.

Results

54 patients were identified who were suitable for inclusion. 12 (22%) patients had a favourable response to NAT according to the CAP grading system. A significantly greater reduction in Ca19-9 observed in the favourable TRG group [mean -2359 U/mL] compared to the unfavourable TRG group [mean -569 U/mL (p<0.001). The type of chemotherapy agent received, the number of cycles or whether the patient had a dose reduction during their NAT course did not differ significantly between the groups. The time from diagnosis to chemotherapy and time from end of chemotherapy to surgery were also similar between the groups.

Conclusions

In this bi-institutional retrospective study, neither chemotherapy factors nor treatment intervals were not found to be significantly related to pathological tumour response to NAT in PDAC patients undergoing resection. Given that a favourable pathological response has been related to improved oncological outcomes, future research should concentrate on further mechanisms that may influence the response of PDAC tumours to NAT, such as gene expression and the tumour microbiome. Given that NAT is also a relatively new approach, further multicentre collaboration should be encouraged to increase numbers of patients for study.
HPB P14 Setting the Foundation: Empowering Junior Doctors in Complex Specialties through Induction Excellence
Authors: Al Saoudi Tareq , Chawla Kanika , Pollard Cris , Isherwood John , Bhardwaj Neil , Garcea Giuseppe , Dennison Ashley
Published: November 2023

Background

The newly qualified junior doctors in the UK face challenges due to limited experience and unfamiliarity with their rotations. We aim to share the experience of establishing a Hepatobiliary and Pancreatic (HPB) surgery specific induction program at University Hospitals of Leicester NHS Trust and assess its impact on doctors' knowledge and experience.

Methods

A booklet was distributed to new junior doctors and a two-hour structured teaching session was also conducted, with pre- and post-session assessments using multiple-choice questions and a feedback survey. The survey measured understanding of HPB anatomy, interventions, and satisfaction with the teaching methodology.

Results

Prior to the teaching session, levels 4 and 5 understanding of HPB anatomy were reported by 18.1% of participants. After the teaching session, there was a significant improvement in understanding, with levels 4 and 5 reported by 95% of participants, and only 5% reporting level 3. Similar improvements were observed in other tested categories. Factual knowledge also improved, with a 38% increase in correct responses on basic HPB and surgical knowledge questions. Participants found the session helpful and well-structured, with 60% strongly agreeing and an additional 30% agreeing. The delivery method was deemed appropriate by the majority.

Conclusions

Specialty-specific induction programs are crucial for providing support and ensuring the development of competent doctors. Efforts should be made to create supportive working environments for junior doctors to alleviate stress and improve their well-being.
HPB P16 How relevant are additional histological features when predicting five-year recurrence/survival rates afterpancreatoduodenectomy for ampullary adenocarcinoma? Results from the Recurrence After Whipple’s (RAW) study
Authors: Hall Thomas , Kahar Nurul , Nadeem Nabeegh , Shah Nehal
Published: November 2023

Background

Providing they have an appropriate performance status, patients with ampullary adenocarcinoma (AA) may be offered pancreatoduodenectomy (PD) with curative intent. Aggressive histological tumour characteristics are known to correlate with poor long-term outcomes. This study aimed to quantify how peripancreatic fact invasion (PPFI), perineural invasion (PNI), microvascular invasion (MVI) and lymphatic invasion (LI) correlate with five-year recurrence and five-year survivalrates.

Methods

Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Patients with histologically confirmed AA were identified and compared by their PPFI, PNI, MVI and LI statuses. Fisher’s exact test was used for the comparisons.

Results

A total of 394 patients (26.5%) had AA confirmed. Incidence rates of PPFI, PNI, MVI and LI were 37.8%, 46.1%, 45.2% and 58.6%, respectively. Five-year recurrence was significantly higher in patients demonstrating PPFI (58.9% vs 34.3%, p=0.0005), PNI (56.6% vs 34.0%, p=0.0001), MVI (60.2% vs 34.2%, p<0.0001) and LI (54.7% vs29.2%, p<0.00001). Five-year survival was significantly lower in patients with PPFI (29.4% vs 62.9%, p<0.0001), PNI (40.4% vs 64.8%, p<0.0001), MVI (43.0% vs 61.3%, p=0.003) and LI (44.1% vs 65.0%, p<0.0005). Patients with PPFI, PNI, MVI and LI were significantly more likely to have histological T3-4 disease (vsT1-2, all p<0.0001).

Conclusions

In our multicentre study of AA patients who underwent PD, less than half had histological evidence of PPFI, PNI or MVI, but a majority had LI. All of these features were associated with increased recurrence and reduced survival rates. However, this likely reflects the fact that these features all correlate with more advanced histological disease.
HPB P18 Continuous drain irrigation as a risk mitigation strategy for postoperative pancreatic fistula; a meta-analysis
Authors: Llwyd Hughes Daniel , Hughes Aron , Gordon-Weeks Alex , Silva Michael
Published: November 2023

Background

Postoperative Pancreatic Fistula (POPF) formation serves as the principle cause for the significant morbidity and mortality rates observed following pancreatectomy. Several different POPF mitigation strategies have been previously trialled, with variable success. Continuous drain irrigation as a treatment strategy for infected pancreatic necrosis has previously been described as an effective treatment strategy, however its role following pancreatectomy has yet to be determined.

Methods

A meta-analysis of the pre-existing literature was performed. The primary endpoint was determining whether continuous drain irrigation reduced POPF rates following pancreatectomy. Secondary endpoint evaluated its impact on post operative morbidity, mortality and length of stay. Analysis of dichotomous variables (complication rates) was calculated utilising the odds ratio (OR) with 95% confidence interval (CI) with the Mantel–Haenszel method with a random effects model. Continuous data (length of stay) was assessed using mean difference (MD) and 95% CI with the inverse variance random effects model. Data was tabulated and visualised through the creation of forest plots.

Results

Nine articles involving 782 patients was included in this meta-analysis. Continuous drain irrigation use was associated with a statistically significant reduction in POPF rates (OR (95% CI) 0.40 (0.19-0.82), p=0.01). Upon subgroup analysis, a significant reduction in clinically relevant POPF was also noted (OR 0.37 (0.20-0.66), p = 0.0008). A reduction in post operative complications was also observed: delayed gastric emptying (0.45 (0.24-0.84), p = 0.01) and the need for re-operation (0.33 (0.11-0.96), p = 0.04). This reduction in post operative complications rates also translated into a reduced post operative length of stay (MD -2.62 (-4.97 - -0.26), p =0.03).

Conclusions

Continuous drain irrigation following pancreatectomy serves as an effective risk mitigation strategy against POPF.
HPB P19 Post-hepatectomy liver failure: A timeline centered review
Authors: Bekheit Mohamed , Grundy Lisa , Salih Ahmed K A , Bucur Petru , Vibert Eric , Ghazanfar Mudassar
Published: November 2023

Background

Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. Whilst the literature addressing PHLF appears ubiquitous, there is no specific structure that summarizes the evidence that can guide surgeons regarding the timeline of the preventive measures against PHLF. The objective of this review is to summarize the published measures and their sources of evidence, in a timeline centered way around the index (i.e., definitive) hepatectomy, thus, summarizing the practice in prediction, prevention, and treatment.

Methods

This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black’s checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis.

Results

This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade.

Conclusions

Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
HPB P20 Radical Single Stage Liver Resection of Bilobar Colorectal Liver Metastases
Authors: Patel Pranav , Doyle Joseph , Yeung Derek , Patel Nikhil , Kumar Sacheen , Bhogal Ricky
Published: November 2023

Background

Surgical resection of Colorectal Liver Metastases (CRLM) offers the best long-term patient survival with current 5-year survival rates of 50%. However, bilobar CRLM often require an individualised patient approach with the primary goals being oncological resection of metastases and adequate future liver remnant. A number of surgical approaches can be used for bilobar CRLM including resection ± ablation, two stage hepatectomy ± portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy (ALPSS), or extended hepatectomy. We describe our approach of single stage parenchymal preserving (SSPP) liver resection for bilobar CRLM.

Methods

All patients with bilobar CRLM that underwent liver resection in a single, tertiary, specialist cancer centre in the UK between April 2018 to December 2021 were included. All liver resections were carried out using an open approach and 6-8 weeks after the cessation of chemotherapy. Pringle was used in all patients. We assessed peri-operative and oncological outcomes as well as disease-free (DFS) and overall (OS) patient survival.

Results

A total of n=42 patients underwent SSPP surgery during the study period. Median age was 54 years (range 36-71) and 93% were performance status=0. Pre-operative chemotherapy was administered in n=39 patients. A median of 4 lesions were resected (range 3-12). Median blood loss was 450mls (range 115-2500mls). R0 resection rate was 95%, with no post-operative liver failure and no peri-operative mortality. Bile leak rate was 10% and n=1 required massive blood transfusion. Median DFS was 13 months, and n=26 patients recurred by the end of the study period. Of these, n=14 were suitable for further treatment. Five-year OS was 77%.

Conclusions

SSPP liver resection for bilobar CRLM is associated with low peri-operative complications and good oncological outcomes. Early recurrence is noted but patients remain eligible for further liver- directed therapies or systemic treatment allowing for good overall patient survival.
HPB P21 A Systematic review and Narrative Synthesis of Health Economic Evaluation of single use duodenoscopes
Authors: Elnour Abdolazeem , Subramanian Kumaresh , YKS Viswanath
Published: November 2023

Background

Multidrug-resistant infections transmitted through duodenoscopes in ERCP procedures have raised significant concerns. In response, the U.S. Food and Drug Administration (FDA) has suggested shifting from traditional reusable duodenoscopes to newer, more innovative designs. These new models, including completely disposable duodenoscopes and those with disposable endcaps, aim to enhance cleaning efficiency and reduce infection risks. While sterile, single-use duodenoscopes have been a breakthrough in eliminating cross-infections, their adoption poses cost-related challenges.

Methods

We conducted a systematic literature search across various databases for studies that examined the cost-effectiveness of these two types of duodenoscopes. Four studies met our inclusion criteria, involving diverse settings and study designs, including cost-effectiveness, cost-utility, and cost-minimization analyses.

Results

All four studies suggested that single use duodenoscopes could be cost-effective compared to reusable ones under certain circumstances, such as specific infection rates, procedure volumes, and willingness to pay thresholds. However, limitations in the generalizability of findings were noted, and the quality of evidence varied across studies.

Conclusions

Current evidence indicates potential cost-effectiveness for single-use duodenoscopes, although it is context-dependent. More robust, high-quality studies are needed to confirm these findings and further explore the cost-effectiveness in various clinical settings and scenarios. The potential environmental impact of single use duodenoscopes warrants further exploration.
HPB P22 Improving Time to ERCP for Acute Gallstone Cholangitis Admissions at a District General Hospital: A Closed Loop Audit
Authors: Boyce Louis , Kaldas Fouad
Published: November 2023

Background

The National Institute of Health and Care Excellence (NICE) guidelines recommend that adults with acute gallstone cholangitis receive endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours of diagnosis, especially in the moderate-severe cases. Early intervention is associated with improved patient outcomes. For smaller district general hospitals with limited resources, achieving these targets can be difficult. We audited our management of patients admitted with obstructive gallstone disease (cholangitis and pancreatitis) with aim of improving timely access to ERCP.

Methods

We performed a closed loop audit investigating time to ERCP in patients admitted with acute gallstone cholangitis at a UK district general hospital. Severity was graded according to the 2018 Tokyo Guidelines. Data was collected over a 5-month period (01/05/2023 to 01/10/2023), analysed and presented to the surgical multi-disciplinary team. Additional referral pathways to 3 nearby tertiary care centre for ERCP were established. Post-intervention admissions were re-audited over a second 5-month period (01/01/2023 to 01/06/2023) to assess the effect of the new referral pathways.

Results

Forty-one patients received ERCP for acute gallstone cholangitis (14 mild cases; 17 moderate; 10 severe). Pre-intervention, overall median time to ERCP was 10 days (5–24). For moderate-severe and mild cases median times to ERCP were 8 (5–19) and 28 days (9–46), respectively. The new referral pathways reduced overall median time to ERCP to 6 days (4–9). For moderate-severe and mild cases, post-intervention median times to ERCP were 6 days (6–8) and 4 days (4–25), respectively. Median length of stay pre- and post-intervention was 8 (6–13) and 7 days (4–10), respectively.

Conclusions

The management of acute gallstone cholangitis poses a significant burden on district general hospitals, particularly those with limited resources. By establishing additional referral pathways to nearby tertiary care centres, we successfully reduced median time to ERCP for local patients with moderate-severe acute gallstone cholangitis. This change may have may have also contributed to a reduction in overall length of stay and shorter waiting times for ERCP in mild cases of gallstone cholangitis. These findings underscore the importance of collaborative efforts between district general hospitals and tertiary centres to enhance patient outcomes.
HPB P23 Investigating the effect of N-acetylcysteine on outcomes following liver resection: A systematic review and meta-analysis
Authors: Wong Tiffany , Koh Amanda , Brutkowska Aleksandra , Gull Sadaf , Adiamah Alfred , Sanyal Sudip
Published: November 2023

Background

N-acetylcysteine (NAC), classed as an essential medicine by WHO, is an antioxidative agent that facilitates the conjugation of toxic metabolites. In the recent years, NAC has been routinely used to limit ischaemia-reperfusion injury during liver transplantation. There remains, however, a scarcity of large high-quality trials investigating its effectiveness in reducing post-hepatectomy liver failure and associated complications in patients undergoing liver resection. This systematic review and meta-analysis of randomised controlled trials (RCTs) aims to review the effectiveness of NAC in improving postoperative surgical outcomes following liver resection.

Methods

A comprehensive search of the MEDLINE, EMBASE, and Cochrane electronic databases was performed to identify relevant RCTs published between 1947 and December 2022. The outcomes of biochemical markers at post-operative day 1 (lactate, ALT, and INR), length of hospital stay, transfusion rates, and morbidity were extracted from the included studies. Quantitative pooling of the data was based on the random effects model.

Results

Five RCTs reporting on 388 patients undergoing liver resection met the inclusion criteria and were included in the analysis. There were no significant differences in patient demographics between groups. The postoperative lactate was lower in patients receiving NAC (WMD -1.08, 95% CI -1.54 to -0.62, I2= 0%). However, there were no differences in the postoperative INR (WMD 0.02, 95% CI -0.18 to 0.22, I2= 84%) and ALT (WMD -94.94, 95% CI -228.46 to 40.38; I2= 97%). More importantly, there were no statistically significant differences in the length of hospital stay, transfusion rates, and morbidity between the two groups.

Conclusions

This meta-analysis of RCTs has shown that the administration of NAC in patients undergoing liver resection did not alter important biochemical parameters suggesting any real effectiveness in reducing post-hepatectomy liver failure. There were no improvements in the clinical outcomes of length of stay, transfusion rates, and overall morbidity.