bluuebunny/crossref_metadata_2025 huggingface dataset:
OGBN O09V Multi-modal Approach with Fluorescence Imaging, Intraoperative Ultrasound and Laser Lithotripsy in the Laparoscopic Management of Complex Large Bile Duct Stones
Authors: Fernando Sherwin , Latif Javed , Bandlamudi Nanda , Bhatti Imran , Awan Altaf
Published: November 2023

Background

Choledocholithiasis is a common condition with various presentations. There are several approaches through which this can be managed. This presentation aims to explain novel techniques and various modalities in managing complex bile duct stones successfully with minimal invasive approach.

Methods

This video presentation depicts the procedure performed for large CBD stones with the use of indocyanine green (ICG) and intraoperative ultrasound (IOUS). The patient is a 61 year old gentleman presented with abdominal discomfort and deranged liver functions. Cross sectional imaging showed 2 large CBD calculi and attempt at endoscopic retrograde cholangio-pancreatigoraphy (ERCP) failed due to large impacted stones. Decision was made to proceed to single stage laparoscopic cholecystectomy and common bile duct exploration with use of ICG, IOUS and laser lithotripsy to achieve successful clearance of CBD.

Results

At laparoscopy, the CBD and common hepatic artery were identified with ICG and IOUS. A vertical choledochotomy was performed and choledochoscopy undertaken. Attempts to retrieve the stone with extraction basket were not successful. Laser lithotripsy was used to break the stones into smaller fragments which were subsequently retrieved using atraumatic graspers and extraction wire. Post operative period was uneventful and the patient was discharged home on day 2. Face to face follow-up at 6 weeks confirmed good recovery.

Conclusions

Laparoscopic management of complex CBD stones is challenging. Despite advances in endoscopy intervention, the role of surgery is irrefutable. Advanced laparoscopic skills and experience in bile duct exploration with advanced minimally invasive instruments and equipment are critical to achieve optimal patient outcomes, and mitigated the chances of conversion to open surgery which its associated morbidity. This presentation demonstrates a safe technique while working in the hostile area of the inflamed hepatocystic triangle and an alternative method in the retrieval of large common bile duct stones following failed ERCP.
OGC O03 Evolution in Laparoscopic Gastrectomy from a Randomized Controlled Trial through National Clinical Practice
Authors: Markar Sheraz , Visser Maurits , Luyer Misha , Nieuwenhuijzen Grard , Gisbertz Suzanne , Van Berge Henegouwen Mark , Ruurda Jelle , van Hillegersberg Richard
Published: November 2023

Background

Following Randomized Controlled Trials (RCT), the dissemination of complex interventions has been poorly studied. The LOGICA RCT included 10 Dutch centers and compared laparoscopic to open gastrectomy. The aim of this present study was to examine the influence of the LOGICA RCT upon the practice and outcomes from laparoscopic gastrectomy within the Netherlands.

Methods

Data were obtained from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) on all gastrectomies performed in the Netherlands (2012–2021), and the LOGICA RCT from (2015–2018). Multilevel multivariable logistic regression analyses were performed to assess the effect of laparoscopic versus open gastrectomy upon clinical outcomes with the LOGICA RCT and DUCA datasets. These analyses were repeated to assess the effect of laparoscopic gastrectomy upon outcomes before, during, and after the LOGICA trial in the DUCA dataset.

Results

In total, 211 patients from the LOGICA RCT (105 open vs. 106 laparoscopic) and 4,131 patients from the DUCA dataset (1884 open vs. 2247 laparoscopic) were included. In 2012, laparoscopic gastrectomy was performed in 6% of patients, increasing to 82% of patients in 2021. No significant effect of laparoscopic gastrectomy on postoperative clinical outcomes was observed within the LOGICA RCT. Nationally within DUCA, a shift towards a beneficial effect of laparoscopic gastrectomy upon complications was observed, reaching a significant reduction on overall complications (aOR:0.62; 95%CI:0.46-0.82), severe complications (aOR:0.64; 95%CI:0.46-0.90) and cardiac complications (aOR:0.51; 95%CI:0.30-0.89) after the LOGICA trial.

Conclusions

The wider benefits of the LOGICA trial include safe dissemination of laparoscopic gastrectomy across the Netherlands. The robust surgical quality assurance programme in the design of the LOGICA RCT was crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during surgeons learning curve.
OGC O08 Quantification of fluorescence angiography for visceral perfusion assessment in gastric conduit reconstruction: measuring agreement between two software algorithms
Authors: Nijssen D J , Joosten J J , Osterkamp J , van Elzen R B , Svendsen M B , Dalsgaard M W , Homopes R , Gisbertz Suzanne , Achiam M P , van Berge Henegouwen Mark
Published: November 2023

Background

Building evidence suggests that fluorescence angiography is capable of reducing anastomotic leakage rates. Many software-based quantification algorithms have been developed aiming to obtain an objective measure for intraoperative visceral perfusion at the anastomotic site. Validation and comparison of these models in the current literature is scarce. The aim of this study was to measure agreement between two independently developed software algorithms for the quantitative assessment of visceral perfusion using indocyanine green fluorescence angiography.

Methods

81 video recordings from patients who underwent fluorescence angiography-guided Ivor Lewis esophagectomy with gastric conduit reconstruction between August 2020 and February 2022 were available for analysis. In this dataset, we standardized patient, theatre, camera and imaging display variables. Recordings were analyzed retrospectively based on intraoperatively selected regions of interest using two software based-quantification algorithms (AMS and CPH). Quantitative parameters derived from the fluorescence time curve (FTC) were recorded. The comparison focused on the predefined primary outcome variable for quantitative perfusion assessment "normalized maximum slope". Agreement between the two software algorithms was evaluated in a Bland-Altman analysis. Quantitative parameters in patients with anastomotic leakage were compared to those without.

Results

Out of 81 video recordings, 70 could be processed using both algorithms. The output values for the normalized maximum slope from the AMS and the CPH software held a moderate-to-strong correlation in a linear regression model (R-squared: 0.544, p<0.001). The Bland-Altman plot indicated a mean±SD difference of 0.037±0.018 arbitrary units for the normalized maximum slope, with significant differences between the two software measurements (p<0.001). Proportional bias was observed using linear regression in the Bland-Altman plot (R-squared=0.715, p<0.001). Disparities between the two measurement methods became proportionally larger among higher mean values. Neither of the two software methods showed a significant difference in perfusion measurement between the anastomotic leakage and no leakage groups (p=0.32 and p=0.51). Differences in signal processing, such as smoothing techniques and window selection, were identified as potential factors contributing to the disparity in outcomes.

Conclusions

The two software-based quantification methods for visceral perfusion demonstrated significant differences. Varying agreement among quantification methods should be considered while interpreting studies that report quantitative parameters and derived thresholds for clinical endpoints, as there may be a limited external validity.
OGC O09 Fluorescence lymphography using indocyanine green in the prevention of chyle leakage after minimally invasive esophagectomy
Authors: Henckens S P G , van der Aa Dillen , Nijssen D J , Eshuis W J , Gisbertz Suzanne , van Berge Henegouwen Marc
Published: November 2023

Background

For oncological reasons, the thoracic duct is resected during esophagectomy for cancer. Its anatomy and vulnerability render it prone to injury and mainly side branches and collaterals are often hard to visualize. Chyle leakage is one of the most challenging complications in esophagectomy, with an incidence of 14-21%. The clinical implications for patients are prolonged thoracic drainage and hospital admission, additional reinterventions, unpleasant dietary restrictions, and decreased long-term survival. Fluorescence lymphography using indocyanine green (ICG) can accurately visualize the thoracic duct and collaterals, which may possibly reduce the incidence of chyle leakage and intra-operative detected chyle leakage can be treated directly.

Methods

A prospective observational cohort study will be performed. Patients aged over 18 years with resectable (cT1-4a, N0-3, M0) esophageal carcinoma undergoing a minimally invasive esophagectomy will be included. The primary endpoint of the study is postoperative chyle leakage. Secondary endpoints are overall morbidity and mortality, nature of dietary restrictions, reinterventions, hospital costs, 2 year survival rate and quality of life. Twenty-five milligram of ICG is dissolved in 10 ml of sterile water, obtaining a solution of 2.5 mg ICG per mL. In the McKeown esophagectomy, before the thoracic phase, the surgeon administers a bilateral bolus of 2 mL ultrasound-guided into inguinal lymph nodes. In an Ivor Lewis esophagectomy, 2mL of reconstituted ICG will be injected into the small bowel mesenteric root just under the peritoneum of the mesentery, at the level where the jejunostomy is placed. Additionally, 50 mL of cream is enterally administered through the just established feeding jejunostomy. Subsequently, the operating area is inspected for chyle leakage with fluorescence lymphography after thoracic duct ligation and just before terminating the procedure.

Results

We aim to include 50 patients to assess the feasibility of fluorescent lymphography using ICG and enteral cream to prevent chyle leakage after minimally esophagectomy. Inclusion is ongoing. At this time 39 of 50 patients are included. Results will be expected before the congress.

Conclusions

It is hypothesized that as a result of this technique the patients will benefit from lower incidence of postoperative chyle leakage, shorter thoracic drainage, reduced hospital admission, reduced dietary restriction, less re-interventions, and improved overall survival.
AHP P01 A Survey To Explore The Use Of Nutritional Outcome Measures In Clinical Practice By Dietitians In Oesophago-Gastric Cancer Care In The British Isles
Authors: Ford Kate , Grimshaw Kate , Owen Kellie , Alkhaffaf Bilal
Published: November 2023

Background

Dietitians in clinical practice face the challenge of providing high quality care whilst demonstrating clinical effectiveness and continuous improvement. Assessing the effectiveness of dietetic intervention is vital in ensuring the provision of clinically effective dietetic services. Nutritional outcome measures are key in identifying the impact of dietetic interventions; enabling dietitians to objectively measure the effectiveness of their care as well as providing patients, other health care professionals and commissioners with data around the value of care provision. Currently there are no specific nutritional outcomes associated with oesophago-gastric cancer care in the UK.

Methods

A survey was disseminated through direct personal emails to 93 Dietitians known to be working in UGI, a list derived from NOGCA audit sites of 2021, with the aim of assessing the current use of nutritional outcome measures by Dietitians working in oesophago-gastric cancer acute care in the British Isles. Further promotion was directed through a UGI Dietitians Forum and through social media posts. A YouTube video was produced and distributed alongside the survey, with the aim of providing education around identifying nutritional outcomes. The video also aimed to connect personally with people, with a visual presentation from the researcher.

Results

54 responses represented the entire patient journey.

Whilst 72% of respondents reported identifying and documenting dietetic outcomes, the quality of these assessments was low, mainly focusing on weight, weight changes and hand grip strength. Other common themes related to nutritional intake, quality of life and symptom impact. Less common outcomes measured included standardised nutritional assessment (PG-SGA), gastro-intestinal symptom evaluation, optimised prehabilitation, biochemical parameters and patient experience.

There was little standardisation in how outcomes are used and when they were taken. There is no national database available to collate OG nutritional outcome data, representing a missed opportunity to support national benchmarking.

Conclusions

This study has presented not only the inconsistencies in nutritional outcome data collection (definition, timing and tools) and the need for standardisation of outcomes use in this speciality, it has also demonstrated the challenges around the promotion of outcomes measures and application/roll out into clinical practice.

Novel ways of obtaining and evaluating nutritional outcomes will need to be considered. This will form the basis of a further research study, exploring barriers to completion of nutritional outcomes.
AHP P03 Challenges in the nutritional management of patients undergoing Endoluminal Vacuum therapy (EVT) for upper gastrointestinal (UGI) leaks and perforations
Authors: Owen Kellie , O’Mahony Seán , Farooq Naheed , Alkhaffaf Bilal
Published: November 2023

Background

The management of upper gastrointestinal (UGI) leaks and perforations is complex and challenging. Patients often have multiple comorbidities, have undergone major surgical interventions with protracted pathways, and are associated with compromised nutritional states. Endoluminal Vacuum therapy (EVT) is a novel approach to managing UGI leaks that aims to avoid unnecessary major surgical intervention. Optimising nutrition for this cohort is of paramount importance, however, this may be challenging to achieve due to repeated interventions and interruptions in nutritional support. This study aimed to objectively measure and describe some of these challenges and explore areas of development to optimise outcomes for patients.

Methods

A retrospective analysis of all leaks and perforations managed with EVT between September 2018 and June 2023 was undertaken. This included patients who had undergone cancer resections (oesophagectomy and gastrectomy), bariatric surgery and those presenting with benign disease (e.g. oesophageal perforation and iatrogenic injury). The setting was a regional tertiary oesophago-gastric and bariatric centre in the North-West of England serving a population of 3.5 million people. A comprehensive dataset relating to the nutritional status of patients preoperatively and the change in nutritional parameters was collected and analysed.

Results

59 patients (43 males; median age 61) were included; 88% were discharged from hospital. Median weight on admission and last EVT was 88.5kg (IQR 51-131kg) and 76.9kg. 31% had >10% pre-admission weight loss (IQR 2.4-30%). Median weight loss to last EVT was 7.1% (IQR +16.5 to -18.1%) vs. 9.4% (IQR +2 to -23%) for overall stay. Initial feeding routes were 46% (27/59) jejunostomy, 41% (24/59) parenteral nutrition (PN), 12% (7/59) PN/jejunostomy, and 2% (1/59) naso-gastric. Median weight loss during admission was less (9%) in the jejunostomy cohort versus the other feeding groups (PN 12.4%, PN/jejunostomy 13.9%, nasogastric 9.2%).

Conclusions

Meeting the nutritional needs in this complex, co-morbid and often nutritionally deplete group is a challenging task. Management algorithms were heterogenous and lacked consistency. An accurate understanding of nutritional requirements was difficult due to a combination of a lack of clinically validated guidelines and little consensus regarding which data points should be used to measure nutritional provision. These issues must be addressed to accurately ascertain the role of nutritional optimisation in this cohort, and to be able to identify modifiable factors and areas of development that may improve patient outcomes.
EGS P01 Embracing a Paradigm Shift: A Single-Centre Experience with the Chole-QuiC Process
Authors: Bird Jonty , Hamid Mohammed , Sellahewa Chaminda
Published: November 2023

Background

Substantial evidence exists for the superiority ofemergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the United Kingdom remain low compared to other developed countries; with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

Methods

A prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital’s subscription to the Royal College of Surgeons of England’s Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between December 2021 and January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with post-operative outcomes.

Results

261/307 (85%) of all suitable acute admissions had an emergency cholecystectomy, compared to 5% the preceding four years. Waiting time dropped from 67 to 5 days. 208 (79.7%) patients were primary presentations. 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. 23 (8.8%) patients underwent a preoperative ERCP and 26 (10%) of patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (OR 0.35p=0.042) and operation times within 7 days (OR 0.32 p=0.037); with worse outcomes in BMI ≥35 (OR 3.32 p=0.005) and operation time >7 days (OR 3.11 p=0.037).

Conclusions

A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.
EGS P04 Recent ten year experience of Boerhaave’s Syndrome Management in a tertiary Oesophago-gastric Surgery Centre
Authors: Ramdin Ashling , Doran Sophie L F , Qureshi Yassar A , Mohammadi Borzoueh , Dawas Khaled
Published: November 2023

Background

Oesophageal Perforation (OP) is a low incidence, high complexity gastrointestinal surgical emergency with associated high mortality rates. A consequence of UK centralisation of oesophago-gastric (OG) cancer surgery is passive centralisation of OG surgical emergencies leading to reduced mortality for OP and lower threshold for surgical intervention by high volume OG cancer surgeons. Boerhaave's Syndrome characterised by Mackler’s Triad (vomiting, thoracic pain and subcutaneous emphysema) represents 30% of OP. UCLH has an OG surgery catchment population of 3 million. We present our experience of managing Boerhaave’s syndrome as an OG cancer centre with a dedicated OG Consultant on-call rota.

Methods

A retrospective review of electronic health records of all adult patients with a radiological diagnosis of OP over a 10 year period from 01/01/2013 to 31/12/2022) at our institution was performed. The inclusion criteria were adult patients with a clinical and radiological diagnosis of Boerhaave’s syndrome. Those with OP due to malignancy, endoscopic, or foreign body perforation were excluded from further analysis. The primary outcome measure was 90-day mortality and the secondary outcome measures were length of stay and reintervention rate.

Results

41 patients with Boerhaave’s syndrome were identified (31 male, 10 female) with median age of 62 (46 - 71). 17 (41.5%) patients presented directly to our institution and 24 (58.5%) were transferred from other hospitals. Primary intervention was surgical in 31 (75.6%), endoscopic in 3 (7.3%) and conservative in 7 (17.1%) patients respectively. Overall 90-day mortality was 12.2% but 6.5% in the surgically managed group. Median length of stay was 58 days (22 - 70). 9 patients had reintervention – 7 (17.1%) had a thoracotomy/thoracoscopic surgery for intrathoracic collections and 2 patients (9.8%) had endoscopic intervention.

Conclusions

This is a report of the experience of managing Boerhaave’s syndrome in a high volume tertiary OG centre. A favourable 90-day mortality rate of 12.2% compares to 38.8% described in a previous UK cohort is likely a result of management in a tertiary centre with appropriate multidisciplinary infrastructure to manage complex patients and provide a consistently high level of perioperative care. The lower mortality rate (6.5%) in the operatively managed group is likely due to patient selection and surgical techniques honed from familiarity with complex cancer and benign oesophageal surgery and working as part of an effective multidisciplinary team.
EGS P05 Evaluating the predictive value of NSQIP surgical risk calculator in patients undergoing emergency laparoscopic cholecystectomy at a single UK centre
Authors: Chen Runzhi , Hussain Nadiya , Goutham Meera , Soggiu Fiammetta , Sheth Hemant
Published: November 2023

Background

Machine learning algorithms for surgical risk predictions have been utilised as an informed consent tool for surgeons and patients. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a surgical risk calculator utilising machine learning to predict adverse postoperative outcomes with surgeon adjustment of risk. However, there is a paucity of validation studies for laparoscopic cholecystectomy data. This study aimed to evaluate the predictive value of the NSQIP calculator in patients undergoing emergency laparoscopic cholecystectomy at a single UK-based centre.

Methods

Preoperative patient characteristics and postoperative outcome data was collected from patients who underwent emergency laparoscopic cholecystectomy between January 2022 and January 2023. NSQIP surgical risk scores were retrospectively calculated using preoperative characteristics and risk factor data. Surgeon adjustment of risk was set at the default for all patients. The predicted rates of postoperative complications, serious complications (definition as per the NSQIP calculator), and hospital readmission were compared to the observed rates using Brier scores.

Results

Eighty-five patients were analysed. The median age was 50 (range 19-91) and BMI was 29 (range 21-44). The NSQIP predicted an overall complication rate of 4.2%. Overall observed complication rate was 3.7% and included hospital-acquired pneumonia (n=1), pancreatitis (n=1), and postoperative atrial fibrillation (n=1). The predicted and observed complication rates were comparable (4.2% vs 3.7% respectively, Brier score 0.066). Likewise, the observed rate was also lower than predicted rate for serious complications (2.4% vs. 3.4% respectively, Brier score 0.047). The observed rate of hospital readmission was similar to predicted risk (3.7% vs. 4.0% respectively, Brier score 0.033).

Conclusions

In this cohort, the NSQIP surgical risk calculator demonstrated acceptable predictive ability for the risk of postoperative complications after emergency laparoscopic cholecystectomy. There was a propensity of the NSQIP calculator to overestimate the risk of complications, within the limitations of the small sample size and retrospective nature of this study. Further studies are warranted to assess the ability of the NSQIP tool to predict the risk of surgery-specific complications.
EGS P06 Pattern of oesophago-gastric injuries and its outcome in major trauma and tertiary UGI centre
Authors: Ahmed Salman , Turner Paul , Ward Jeremy , Khan Rehan , Pursnani Kish , Shetty Vinutha
Published: November 2023

Background

Oesophago-gastric injuries in major trauma are relatively rare. These injuries are known to be associated with high morbidity and mortality. Major trauma involving oesophagus and stomach are linked with high velocity, high impact blunt or penetrating force. There is also a strong association between oesophago-gastric injuries and other systemic injuries including thoracic, major vessels, skull, brain and abdominal viscerae. In this study we aimed to evaluate the pattern of injury in oesophageal and gastric major trauma its association with widely used injury severity score (ISS), multi organ system involvement, survival and factors affecting mortality.

Methods

Patients presenting between January 2012 and December 2022 as major trauma as moderate / severe trauma (ISS > 9) with oesophageal and gastric injuries were included in this study. Retrospective analysis was carried out on prospectively maintained trauma data base in an urban major trauma centre with specialist tertiary upper GI cover. Mechanism of injury, ISS and mortality were calculated. Analysis was carried out on variables to identify factors contributing to overall index admission mortality. MedCalc ® was used to perform statistical analysis.

Results

A total of 8984 patients presented in urban major trauma centre with moderate to severe trauma (ISS >9). Among them 13 had gastric injuries and 3 had oesophageal injuries (total n=16). Mechanism of injury in gastric patients was blunt force in 8 (61.5%) and penetrating force was in 5 (38.5%) patients whereas all oesophageal injuries were linked with penetrating trauma. Median ISS in gastric injuries was 17 and in oesophageal injuries was 34. Overall mortality was 31.2%(n=5). Variables including high ISS, thoracic injury, diaphragmatic rupture, skull injuries & blood transfusion were linked with mortality on multivariate logistic regression.

Conclusions

Our study finds an association of oesophago-gastric injuries with high impact penetrating and blunt trauma. Presence of oesophageal and gastric injuries are surrogate indicators of severity of trauma, it is not only associated with high ISS but also has relatively high mortality. Therefore, early involvement of specialist senior decision maker in time critical setting is recommended. Due to scarce volume of OG trauma, national UGI trauma collaborative can be helpful to share experience, learn lessons and promote research.
EGS P07 Upper GI Injury trends, rates, and mortality in major trauma centre
Authors: Ahmed Salman , Shetty Vinutha , Date Ravi , Ward Jeremy , Pirsnani Kish , Turner Paul
Published: November 2023

Background

Trauma is one of the leading causes of death in UK. Moderate and severe trauma presents with multi-organ / multi cavity involvement. Robust resuscitation, methodical approach, prompt diagnosis and early surgical intervention have an impact on mortality. Injury severity score (ISS) is widely used across trauma centres to estimate severity. It is found to be linked with mortality and outcome. An ISS of 9-15 classes as moderate and an ISS of > 15 is considered severe trauma. In this study we aimed to evaluate the mortality associated with upper GI injuries I.e., oesophagus, stomach, duodenum, liver, pancreas, spleen and diaphragm.

Methods

Retrospective analysis was carried out on prospectively maintained trauma data base in an urban major trauma centre (MTC) with tertiary upper GI surgical cover. All patients presenting with moderate or severe trauma based on ISS between 1st of January 2012 to 31st of Dec 2022 were included in this study. Proportion of upper GI injuries in reference to overall major trauma cases were analysed. All cause index-admission mortality associated with upper GI injuries was calculated.

Results

A total of 8984 patients presented in this centre with moderate - severe trauma (ISS>9) during study period. Overall mortality was found to be 8.6% (n=780). Liver injuries were seen in 228 (2.5%), splenic injuries in 226 (2.5%), diaphragmatic rupture in 26 (0.29%), oesophago-gastric (OG) trauma in 16 (0.2%) and duodenum and pancreatic injuries in 15 (0.17%) patients. Highest mortality was found in OG trauma with 31.2%, followed by diaphragmatic injures with 19%, liver injuries with 12.7%, splenic injuries with 9.3%. Upper GI injuries are associated with high median ISS of 28.5 and present as polytrauma spectrum.

Conclusions

Although oesophago-gastric injuries are rare but, have relatively high mortality. Early aggressive resuscitation, involvement of oesophago-gastric or HPB surgeons, and multidisciplinary approach is required to deal with such complex injuries to get the best outcome. Robust national collaborative mechanisms across MTCs should be encouraged to share experiences, learn lessons and promote research.
EGS P14 Improving Management of Obstructive Jaundice: A Single-Centre Experience
Authors: Chan Calvin , Jamson Alexander Harry , Cheng Timothy , Patwardhan Maneesha , Brewer James , Galloway Daniel , Collins Carole , Smith Jason , Kamocka Anna
Published: November 2023

Background

Timely management is essential in preventing recurrence of gallstone disease and The National Institute for Clinical Excellence (NICE) recommends that laparoscopic cholecystectomy (LC) should be performed within seven days of admission. However, there remains wide variation between NHS Trusts in managing gallstone disease. As part of an ongoing surgical quality improvement project, a restructured Upper Gastrointestinal Surgery (UGI) firm was created (with three dedicated UGI consultant surgeons, one specialist registrar, one foundation doctor), in close collaboration with interventional gastroenterologists and radiologists. The impact of this new service on gallstone disease management has been closely monitored.

Methods

A prospective database was maintained including patients presenting emergently with obstructive jaundice and/or common bile duct stones at our district general hospital (DGH) in the 6-month timeframe before (September 2021 to February 2022) and after (September 2022 to February 2023) implementation of the new UGI service. Outcomes included time from presentation to magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and LC.

Results

26 and 38 patients with obstructive jaundice were admitted in the 6-month periods before and after UGI firm implementation, respectively. There were significant reductions in time from admission to receiving ERCP (6.6 days versus 40.2 days, p<.001), and outpatient LC (61.8 days versus 194 days, p=.02). There was also marked improvement in obtaining MRCP (2.5 days versus 5.2 days). After UGI firm implementation, 35% of eligible patients were offered an inpatient LC which were all performed within seven days (mean 6.3 days), versus none previously.

Conclusions

A dedicated UGI service significantly improved the treatment process for patients presenting with obstructive jaundice at our DGH. As part of ongoing quality improvement work, solutions such as introducing a ‘golden patient’ to the NCEPOD list, a ‘hot slot’ on the elective gallbladder list or a dedicated weekly ‘hot’ gallbladder list are currently being investigated. Equipment for laparoscopic transcystic common bile duct exploration is also being considered to alleviate the need for ERCP prior to surgery.
EGS P15 Perforated Stomach within an Inguinal Hernia: A Rare Case Report and Surgical Management
Authors: Shalaby Samar , Marinos Spyros , Gammeri Emanuele
Published: November 2023

Background

Inguinal hernias are a common surgical condition requiring urgent medical attention. While complications of inguinal hernias are frequently encountered, the presence of a stomach herniation within this anatomical site is an exceptionally rare occurrence. This rare phenomenon presents diagnostic challenges and necessitates prompt surgical intervention. This case report aims to provide a detailed account of a patient with a perforated stomach within an inguinal hernia, emphasizing the unique clinical presentation, diagnostic dilemmas, and the subsequent surgical management required for such a complex condition.

Methods

We report the case of an 83-year-old male who presented with severe abdominal pain and a tender mass in the left groin. Clinical examination revealed an irreducible inguinal hernia with signs of peritonitis. CT scan confirmed a giant incarcerated inguinal hernia containing part of the stomach with associated gas and fluid collection. An emergency open hernia repair was attempted but swiftly converted to an exploratory laparotomy. The hernia content was reduced intraabdominally, surprisingly revealing a posterior stomach wall perforation. Damage-control suture repair, washout, and laparostomy were performed. Tragically, he succumbed to multiorgan failure soon after in ITU.

Results

The occurrence of a perforated stomach within an inguinal hernia is an exceptionally rare and diagnostically challenging entity. Timely diagnosis and intervention are vital to prevent life-threatening complications. Imaging, particularly CT scan, aids in diagnosis and surgical planning. Prompt surgical management, involving hernia reduction and gastric repair, is crucial for optimal outcomes. play a critical role in identifying the gastric perforation and guiding the surgical approach.

Conclusions

This case underscores the importance of recognizing rare complications, such as stomach herniation in inguinal hernias. Heightened awareness and appropriate use of imaging facilitate accurate diagnosis and guide surgical interventions. Timely surgical intervention is essential in reducing morbidity and mortality associated with this rare presentation.
EGS P17 Expanding the technical armamentarium to treat complex oesophageal perforations with Endoluminal Vacuum Therapy
Authors: Obuekwe Chukwuemeka , Saqib Imad-Ud-Din , Mittring Artur , Gourgiotis Stavros , Hardwick Richard , Sujendran Vijay , Safranek Peter , Bennett John , Noorani Ayesha , Hindmarsh Andrew
Published: November 2023

Background

Endoluminal vacuum therapy (EVT) is increasingly the default treatment modality for oesophageal leaks. If the leak cavity is large or has a dependent element, placement of the endoluminal vacuum device within the leak cavity facilitates healing. However, accessing the leak cavity can be challenging when the oesophageal defect communicating with the leak cavity is small, and it is tempting to default to luminal EVT. This can lead to a EVT failure. We present a case where luminal EVT in the presence of an established leak cavity with a narrow inlet resulted in stagnation of therapy requiring an alternative technical approach.

Methods

An 80-year-old high-risk female with Boerhaave's syndrome presented with a 4cm esophageal defect and a large mediastinal leak cavity. An ad-hoc endovacuum therapy (EVT) device, consisting of V.A.C granufoam (KCI) attached to a 14Fr nasogastric (NG) tube, was placed in the leak cavity at -125mmHg pressure. The EVT device was replaced every 3-8 days. After 101 days, luminal EVT was adopted due to cavity narrowing. Partial closure of the esophageal defect was achieved, but a persistent mediastinal abscess communicated through a residual pinhole defect. Additional luminal EVT and image-guided drainage couldn't resolve the persistent esophageal fistula, confirmed by contrast-enhanced CT.

Results

Endoluminal access to the leak cavity was re-established by dilating the fistula using a TTS 12mm radial expansion wire-guided balloon catheter enabling re-establishment of intra-cavity EVT. Having regained access, further intra-cavity EVT using an ad-hoc EVT device fashioned from black granufoam (KCI) sutured to a 10Fr or 12Fr ng tube with 125mmHg negative pressure was applied. The EVT device was changed every 3-6 days. After further 25 days of EVT complete healing was observed.

Conclusions

Whilst intraluminal EVT has a role in oesophageal leaks associated with small leak cavities which have no dependent element, larger leak cavities require intra-cavity EVT. If access to the leak cavity is challenging due to the small size of the oesophageal defect, endoscopic measures to facilitate endoluminal access to the leak cavity such as dilation of the defect can be safely employed to enable delivery of intra-cavity EVT. This should be considered when endoluminal access to the leak cavity is prevented due to the small size of the defect obviating the need for other more invasive interventions such as surgery.
EGS P21 Hard to swallow, hard to treat
Authors: Ishak Athanasius , Smith Jacob , Nanda Akriti , Dimaggio Francesco , Thomas Rhys
Published: November 2023

Background

Deliberate foreign body ingestion (DFBI) presents unique medical, surgical, and ethical challenges. Often, patients with psychiatric conditions repeatedly ingest foreign bodies, leading to frequent emergency department visits. Standardised management guidelines are lacking, resulting in high hospitalisation rates, interventions, and complications. This study focuses on recent DFBI cases at our institution, providing insights into this complex condition and holistic management.

Methods

Patients admitted by the surgical team at Croydon University Hospital between 2017 and 2023 with DFBI were included. Data on demographics, clinical presentation, investigations, and management were collected. Complications, hospitalisations, interventions, and cost analysis were recorded.

Results

Eight patients presented a total of 52 times. The incidence of DFBI increased over time. Swallowed objects included knives, needles, magnets, glass, batteries, pencils, gloves, lighters, and screws. Each patient underwent an average of 21 X-rays, 2 CT scans, and 3 OGDs. Eleven laparotomies and 1 laparoscopy were performed. The average length of stay was 44.5 days. Complications included pulmonary embolism, pneumonia, enterotomy, hernia, and infection. The average cost per patient was £30,866.25.

Conclusions

DFBI poses a significant burden on healthcare systems. Patients face radiation exposure and repeated invasive interventions, necessitating a comprehensive approach. Understanding DFBI from a biopsychosocial and ethical perspective is crucial. A multidisciplinary team should be involved early, with clear goals. Further research is needed for optimal management pathways.
EGS P22 Prophylactic PPIs in NOF Fractures to prevent UGI bleed- Can It Be a Lifesaving Intervention?
Authors: Khawaja Zeeshan , Jamal Zohaib , Thakker Vivek , Zafar Nowera , Adnan Naqqash
Published: November 2023

Background

Assess the incidence of UGI bleed in patients with NOF fractures. Develop trust-based guidelines to include PPIs in the management of such patients.

Methods

A total of 119 patients who were admitted with NOF fractures between January and March 2022 were included. All the patients admitted to RAEI with NOF fractures were included in the study. All the patients with a previous diagnosis of GORD, peptic ulcers, or perforated peptic ulcers and those who were already taking PPIs before admission were excluded from the study. Information was collected about the hospital number, age, gender and if there was any gastrointestinal bleeding was noticed in such patients during the hospital admission.

Results

Our results showed that most of the patients who were admitted with NOF fractures were elderly. A total of 5/119 patients had major gastrointestinal bleeding during there hospital admission thus warranting further procedures such as endoscopy, transfusions, and prolonged hospital stay.

Conclusions

Elderly patients with NOF fractures are at an increased risk of stress-related mucosal damage and subsequent UGIB. Due to the devastating and potentially threatening complications of mucosal damage, preventative measures are mandatory. Therefore, PPIs should a routine part of drug prescription in patients admitted with NOF fractures. This can not only help prevent this potential bleeding but can also be cost-effective in terms of preventing prolonged stays and readmissions. A reaudit is planned to be done in 1 month's time after the implementation of the changes.
EGS P29 Evaluating Compliance and Identifying Barriers to Timely Cholecystectomy in Gallstone Pancreatitis: A Retrospective Study
Authors: Salem Rola , Bush Alexander , Hale Emily , Poulton Theodore , Kostalas Marcos
Published: November 2023

Background

Gallstone pancreatitis is a common cause of acute pancreatitis. Timely cholecystectomy within two weeks of admission is recommended by the UK Pancreatitis Guidelines and NCEPOD to prevent recurrent pancreatitis and associated complications. This study aimed to evaluate compliance with these guidelines at a District General Hospital.

Methods

A retrospective analysis was conducted on all patients (n=92) admitted with acute pancreatitis between July 1st 2022, and January 31st 2023. Patient demographics, diagnostic methods, time to surgery, and relevant laboratory values (median amylase, median CRP) were collected and analysed.

Results

35% (n=32) of patients had gallstone pancreatitis. 26 were fit for cholecystectomy. 35% (n=9) were operated on within 2 weeks. Median time to surgery was 7 days and median CRP 133. There were no readmissions within 6 months. The delayed surgery cohort (n=17) had a median time to surgery of >60 days, median CRP 29 and a 59% (n=10) readmission rate . 1 patient had three readmissions. Reasons for delay were: 2 pancreatic necrosis, 1 pregnancy, 1 pneumonia, 1 delirium, 2 bed pressure, and 10 no clinical reason. 5 patients are still waiting for surgery at the time of analysis >6months.

Conclusions

Prior to the COVID-19 pandemic, compliance with UK pancreatitis and NCEPOD guideline was excellent (GIRFT) at our institution. Our findings are that most patients with gallstone pancreatitis are not being operated upon within two weeks. Delays result in hospital readmissions increasing resource use. Most delays were organisational rather than clinical. Patients who were ambulated for operative management within 2 weeks rarely were operated upon within this timeframe. Trust initiatives aimed at COVID-19 recovery prioritised early discharge and repurposed emergency ‘hot lists’ to reduce elective waiting lists. Interventions to increase emergency operating capacity are most likely to improve matters.
EGS P36 Scan every clinical appendicitis before operation. Can we prevent unnecessary operations in this era of CT?
Authors: Khawaja Zeeshan , Jamal Zohaib , Zafar Nowera , Adnan Naqqash
Published: November 2023

Background

Acute appendicitis is the most common abdominal surgical emergency in the world, with around 50,000 acute appendectomies performed annually in the UK. However, appendectomy has been associated with negative appendectomy rates (NARs) of 15%-39% in large series. On the other hand, CT scan is associated with radiations increasing the risk of cancer and considerable cost to the trust.

Methods

Notes of 25 patients admitted with suspicion of acute appendicitis were reviewed retrospectively by the auditors from their admission to the discharge from hospital and CT scan reports were evaluated.

Results

All of the patients seen by the surgical team had a CT scan to confirm the diagnosis of acute appendicitis before surgery. 15/25 patients had a diagnosis of acute appendicitis and all of the histology reports in these patients after the surgery confirmed the diagnosis. 10/25 patients had other diagnosis on CT despite clinical features suggestive of acute appendicitis. Colitis was the second most common cause of abdominal pain after acute appendicitis. 0% negative appendectomy rate was achieved when CT scan was done before the surgery.

Conclusions

This audit concludes that all the patients who present with the clinical suspicion of acute appendicitis should have a CT scan before the surgery to avoid the unnecessary operations however, an audit of 1 year or more would be more beneficial in formulating a clear picture and the development of guidelines.
EGS P41 The Acute Abdomen - An 'A to E' approach
Authors: Bonsi Theona , Alasmar Mohamed
Published: November 2023

Background

The acute abdomen is classified as a surgical emergency which requires prompt intervention or could otherwise result in mortality. A variety of surgical and medical conditions can cause the acute abdomen ranging from appendicitis to diabetic ketoacidosis. Due to the serious consequences of this condition, surgeons need to be efficient and systematic in their initial principle management. The Royal College of Surgeons, last provided a commissioning guide to Emergency General Surgery (acute abdominal pain) in 2014. These are the most up to date guidelines surgical trainees can refer back too.

Methods

We decided to create and advise an easy to follow ‘A to E’ method that trainees can follow.

A includes - A to E (airway, breathing, circulation, disability, exposure/examination), Analgesia, Antibiotics and Amylase

B focuses on blood tests

C discusses radiographic imaging (chest x-ray) and Computerised Tomography (CT) scanning.

D debates when it is appropriate to diagnose and discharge the patient

E discusses when to explore the surgical option

Conclusions

This review aims to provide a concise, memorable A to E approach whilst discussing specific aspects of diagnosis and management in the acute abdomen.
OGBN P01 Outcomes of Prophylactic Total Gastrectomy in Germline CDH1 Mutation Carriers
Authors: Jun Lim Hui , Roberts Geoffrey , Hardwick Richard H , Fitzgerald Rebecca C , di Pietro Massimiliano , O’Neill J Robert
Published: November 2023

Background

Hereditary diffuse gastric cancer (HDGC) is predominantly attributed to CDH1 [E-Cadherin] germline mutation and carries a cumulative lifetime risk of diffuse gastric cancer (DGC) of up to 70%. Definitive treatment remains prophylactic total gastrectomy (PTG) with an attendant risk of morbidity and reduced quality of life. Endoscopic surveillance following the Cambridge protocol is an alternative for selected patients, however, the impact on disease stage and long-term gastric cancer prognosis is not established. This study aims to evaluate clinical and histopathological outcomes following PTG in patients with germline CDH1 mutations with or without prior surveillance at a national HDGC referral centre.

Methods

Retrospective review was performed of clinicopathological outcomes for germline CDH1 mutation carriers who underwent PTG at Addenbrooke’s Hospital between January 2006 and May 2023. Indication for surgery of clinical stage 1 tumours was guided by patient preference, multiple visible lesions and increasing number of signet ring cell (SRC) foci. Endoscopic surveillance was offered to cases with no concerning endoscopic lesion and low number of SRC foci. Patients with confirmed DGC (≥stage 2) at diagnosis were excluded. Standard PTG procedure was open TG with D1 lymphadenectomy and preservation of posterior vagus with D2 lymphadenectomy and truncal vagotomy in selected cases.

Results

48 patients underwent open PTG with D1 (93.8%) or D2 (6.2%) lymphadenectomy. PTG was deferred in 18 patients (37.5%) with median of 3 pre-operative surveillance endoscopies over 22 months (5 to 61 months). Median post-operative length of stay was 7 days (6 to 12). Major morbidity was observed in 1 case (2.1%) with no post-operative mortalities. Final stage was pT1aN0M0 in 43 patients (89.6%) and pT0N0M0 in 5 patients (10.4%). No lymph node metastases were observed and complete gastric mucosal resection was achieved for all. The 5-year estimated overall and disease-specific survival were 100% with median follow-up of 7 years.

Conclusions

PTG remains a robust and effective treatment for patients with pathogenic germline CDH1 mutations who are appropriate surgical candidates. There was no increase in final stage following surveillance in a dedicated specialist service and this remains a safe alternative in selected cases. For patients choosing to proceed with PTG following comprehensive pre-operative counselling, this can be undertaken with low morbidity in a specialist centre. Further long-term data are needed to determine the impact of surgery and endoscopic surveillance on survival, functional outcomes and quality of life.