bluuebunny/crossref_metadata_2025 huggingface dataset:
HPB P24 Quality assurance within multicentre randomised controlled trials of surgical interventions for pancreatic cancer: a systematic review
Authors: Helliwell Jack , Rozwadowski Sophie , Yi Kwan Jing , Bautista Melissa , Blencowe Natalie , Smith Andrew , Pathak Samir
Published: November 2023

Background

Pancreatic cancer surgery is a complex intervention, with numerous studies exploring variations in approach to curative resection with the aim of improving outcomes. Multicentre randomised controlled trials (RCTs) represent the gold standard for evaluating these technical modifications. However, variations in how surgical intervention are delivered across trial sites and individual surgeons can influence results. Surgical quality assurance mechanisms within trial designs attempt to mitigate this by ensuring standardised, high-quality technique and reducing heterogeneity of procedures. This systematic review aimed to identify approaches to quality assurance within multicentre randomised controlled trials of surgical interventions for pancreatic cancer.

Methods

A systematic review was performed by searching MEDLINE and Embase databases between 1st January 2000 and 18th December 2022. Articles were deemed eligible for inclusion if they were a multicentre RCT and evaluated a surgical intervention, technique modification or variation in approach to surgical resection for pancreatic cancer. Data was extracted from included studies using a semi-structured form, with consideration of four prospectively defined quality assurance domains: i) surgical intervention and co-interventions description, ii) surgical technique standardisation, iii) performance monitoring methods, iv) surgeon/ unit credentialing methods.

Results

A total of 1970 studies were identified from the initial search, of which 44 trials were deemed eligible for inclusion. Thirty-six RCTs (81.8%) provided description of the intervention and/or co-intervention. Attempts to standardise technique were described in 33 RCTs (75.0%). However, only 4 trials (9.1%) deconstructed the intervention into its constituent components. Twelve studies (27.3%) described methods used to monitor performance and adherence to the intervention. The most common approaches used were intra-operative photographs (n=7; 15.9%), surgeon self-declaration (n=3; 6.8%), and pathological specimen review (n=2; 4.5%). Ten studies (22.7%) used credentialing methods based on unit entry criteria.

Conclusions

This study provides important data on the utilisation of methods of surgical quality assurance within pancreatic RCTs. With the exception of intervention description, compliance to the remaining domains of quality assurance was low. This may compromise the extent to which observed differences in clinical outcomes are due to the technique being evaluated within these trials. Confidence in the results of future RCTs would be improved by enhanced quality assurance across the four domains described.
HPB P26 Ex vivo normothermic perfusion of liver, kidney and spleen to predict human pharmacokinetics and assess drug delivery
Authors: Clark Tamsyn , Bau Luca , Dengu Fungai , Voyce Daniel , Friend Peter , Carlisle Robert , Coussios Constantin
Published: November 2023

Background

Many emerging therapeutics fail to provide patient benefit due to unpredictable drug delivery and clearance following clinical translation. Normothermic machine perfusion (NMP) can preserve physiological processes in human-sized organs ex vivo, which may facilitate preclinical characterisation of pharmacokinetics and drug delivery.

The performance of ex vivo human and porcine clearance organs (liver, kidney and spleen) to 1) predict human drug pharmacokinetics and 2) assess the delivery of emerging therapeutics was investigated. A small molecule chemotherapy (irinotecan) with well-established pharmacokinetics was delivered to determine the former. Nanotherapeutics and viral vectors, two classes of emerging therapeutics, were delivered to determine the latter.

Methods

Human liver (n=4), kidney (n=4) and porcine liver (n=11), spleen (n=6) and kidney (n=5) underwent NMP. Organ physiology was measured. Irinotecan (Medac) was delivered to human and porcine liver and kidney. Plasma, tissue, bile and urinary irinotecan and its metabolites were quantified by high performance liquid chromatography. Pharmacokinetic parameters were compared to patient data. Non-PEGylated (ThermoFisher) and PEGylated (in-house), nanoparticles were delivered to liver, spleen, and kidney. Nanoparticles were quantified in biological samples by fluorescence. A lentiviral vector (Oxford Biomedica) was administered to liver and viral kinetics and genomic integration determined using RT-qPCR. Noncompartmental analysis was used for pharmacokinetics.

Results

Prolonged physiological preservation (up to 38 hours) of human liver, kidney and porcine liver, kidney and spleen was achieved with NMP. Human and porcine organs support the pharmacokinetic processes of drug distribution, metabolism and urinary and biliary excretion of irinotecan. Moreover, porcine organs successfully predicted human hepatic clearance, renal clearance and total body clearance with an absolute fold error of 1.14, 1.71 and 1.04 when compared to human literature values. Finally, predictable kinetics and biodistribution of PEGylated and non-PEGylated nanoparticles were demonstrated in NMP clearance organs, and NMP liver supported the integration of lentiviral genome into the host hepatocyte DNA.

Conclusions

Ex vivo NMP organs can be used to predict human drug clearance and assess therapeutic delivery; an exciting prospect for preclinical drug development and for the delivery of hepatocyte-targeted therapies, with the potential to reduce the time, cost and risk in developing life-saving treatments for patients.
HPB P27 Prognostication for Patterns of Recurrence After Surgical Resection for Pancreatic Adenocarcinoma
Authors: Ang Andrew , Michaelides Athena , Bank Barts Pancreas Tissue , Kocher Hemant
Published: November 2023

Background

This study aims to investigate patterns and factors affecting recurrence after curative resection for pancreatic adenocarcinoma (PDAC).

Methods

Consecutive patients who underwent curative resection for PDAC (2011-21) and consented to data and tissue collection (Barts Pancreas Tissue Bank) Were followed up till May 2023. Clinico-pathological variables were analysed using Cox proportional hazards model.

Results

Some 91 people (median age 71 years) had a median follow-up of 51 months, with a recurrence rate of 72.5% (n=66: 12 loco-regional alone, 11 liver alone, 5 lung alone, 3 peritoneal alone, 29 simultaneous loco-regional and distant metastases and 6 multi-focal distant metastases at first recurrence diagnosis). The median time to recurrence was 8.5 months (95% CI: 6.6-10.5) and median survival after recurrence was 5.8 months (95% CI: 4.2-7.3). Stratification by recurrence location revealed no differences in time to recurrence. Significant predictors for recurrence by multivariate analysis were lymph node ratio, adjuvant chemotherapy and systemic inflammation index.

Conclusions

No significant patterns of recurrence were found. Lymph node ratio, adjuvant chemotherapy and systemic inflammation index were predictors of PDAC recurrence. More research is needed to investigate predictive factors for PDAC recurrence after curative resection in large prospective national cohorts.
HPB P02 Leiomyosarcoma of IVC
Authors: Shahid Sana , Oiknomou Dimitrios , Florou Evangelia , Menon Krishna , Srinivasan Parthi
Published: November 2023

Background

Leiomyosarcoma of the inferior vena cava (IVC) is a very rare entity with poor 5-year prognosis. Less than 400 cases have been reported in literature. The extent of mass forming lesions is quite progressed upon discovery and multiorgan resection is often required. Here we present our 5year experience and surgical management of this malignancy.

Methods

From 2000 - 2023, 7 cases with IVC Leiomyosarcoma were treated in our institution. The median patient age was 59 years old with female gender predominance involvement. All patients presented with vague abdominal symptoms prompted imaging studies discovering the tumour, or the latter was an incidental finding of a retroperitoneal mass involving the IVC and adjacent organs (liver, kidney, duodenum). Only 4 patients (56%) had preoperative CT guided biopsy confirming the diagnosis and 3 cases were confirmed from post operative histology.

Results

All cases were reviewed in our multidisciplinary meeting and 4 patients (56 %) underwent surgical resection with caval replacement using a graft apart from one case which underwent IVC ligation. Liver resection was required after portal flow manipulation in two cases. Postoperative complications were ascites and chyle leak which were managed conservatively. Resection margins were negative (R0) to all cases. One case recurred and underwent further liver resections. Chemotherapy was offered only to unresectable cases (42%). From resected patients three of them (42%) are still alive with longest follow up of 4.5years post-resection and one died after multiple resections.

Conclusions

IVC Leiomyosarcoma is an aggressive malignancy and requires major surgery upon diagnosis. Surgery is the gold standard treatment since unrespectability upon diagnosis has poor prognosis. Due to rarity of the disease, large studies are difficult to be conducted.
HPB P30 The role of interventional radiology in managing post-pancreatectomy hemorrhage at a major hepatobiliary centre in the UK
Authors: Sarkar Srishti , Chatzopoulou Despoina , Al-Khalili Faris , Karavias Dimitrios , Modi Sachin
Published: November 2023

Background

Pancreatoduodenectomy (PD) is a common surgery performed by hepatobiliary surgeons. Mortality is 5% and morbidity is 30-40%. An important cause is post-pancreatectomy hemorrhage (PPH). As per the International Study Group for Pancreatic Surgery (ISGPS), grade C PPH represents most cases of hemorrhage post-PD and always requires intervention. They tend to be arterial in origin and CT angiogram of the celiac axis and superior mesenteric artery is recommended. Historically, the treatment for PPH was a re-look laparotomy. With the development of interventional radiology (IR) techniques, morbidity and mortality has improved. Transcatheter arterial embolization is a well-established treatment for bleeding.

Methods

Southampton General Hospital is a tertiary centre for hepatobiliary surgery and interventional radiology. All patients who underwent PD between 2019 and 2023 were checked for complications. Patients who developed PPH were selected and their PACs was checked for what investigation they underwent. The findings of the angiogram and intervention done were recorded. Morbidity and mortality data was also collected including whether patients returned to theatre.

Results

Seven male patients aged 57 to 75 had type C PPH. Symptom onset including melaena and haematemesis was between 24 hours to 38 days.

The time to CT from the request was between one to six hours. One patient was bleeding from the gastroduodenal artery stump. The other six patients had no obvious bleeding point identified. Of the seven patients, five had bleeding points identified on angiograms done by IR and underwent embolization. One patient returned-to-theatre for a re-look laparotomy. Two of seven patients died within one year of PPH. One had repeated PPH and had embolization multiple times.

Conclusions

Harnoss et al., (2014) reported that the rate of PPH post PD was 5.9%. The use of angiography with embolization is being adopted worldwide for arterial bleeding in hemodynamically stable patients due to its minimal invasiveness. Even if embolization fails, angiography can help identify the bleeding point and guide surgical management. The reported immediate mortality rate from PPH is 30% and at our centre it was 0% in our small sample size.
HPB P34 A case-controlled study of single-stage versus two-stage approach to managing common bile duct stones
Authors: Amar Hoda , Holmes Matthew , Athanasiou Christos , Aroori Somaiah
Published: November 2023

Background

The most common approaches to the treatment of symptomatic common bile duct (CBD) stones are endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy (two-stage approach) and intra-operative imaging +/- bile duct exploration (BDE) during laparoscopic cholecystectomy (single-stage approach). Intra-operative cholangiogram (IOC) and intra-operative ultrasound (IOUS) are the two common forms of intra-operative imaging. Although IOC is used more frequently, IOUS is safer, non-invasive and can be repeated. The aim of this study was to evaluate outcomes of patients undergoing a single-stage approach with IOUS compared to patients undergoing a two-stage approach.

Methods

This was a retrospective case-controlled study. Outcomes of patients who had a single-stage approach (group 1) between February 2015 and June 2022 were compared with a cohort of patients (matched for age, sex, and co-morbidities) who had a two-stage approach (group 2). Outcomes included the total number of admissions from diagnosis until cholecystectomy, time from initial presentation to surgery, length of stay (LOS), post-operative and post-ERCP complications (including bile leak, pancreatitis and retained stones), readmission rate and mortality within a year.

Results

Seventy-four patients were included (65% female, mean age 56 years, median Charlson Comorbidity Index of 2). The median number of admissions was lower in group 1 (1 vs 3 days, p<0.01). The median waiting time till surgery was 4 days in group 1 (vs 128 days, p<0.01). The median LOS for group 1 was 5 days (vs 7 days, p=0.08). Overall complications were lower in group 1 (5% vs 11%, p=0.79). Complications included bile leak (5% vs 0%), pancreatitis (0% vs 8%) and retained stones (0% vs 3%). Readmission rate was 3% vs 16% (p=0.66). Overall mortality was zero.

Conclusions

Patients who were managed for CBD stones via the single-stage approach had significantly fewer hospital admissions and shorter waiting time to cholecystectomy. There was no significant difference in LOS, rate of complications or readmissions between the two groups. We therefore advocate the use of the single-stage approach using IOUS routinely over ERCP in the management of symptomatic CBD stones.
HPB P35 A snapshot analysis to identify ideal interval between liver imaging and resection
Authors: White Ayesha , James Rhiannon , Karteszi Hedvig , Skipworth James , Abbadi Reyad , Van Laarhoven Stijn
Published: November 2023

Background

An increase in waiting times has been seen across all NHS service provisions in the last few years due to post-pandemic backlog, staffing issues, bed and theatre pressures. This has led to increasing intervals between cancer diagnosis and surgery, which may negatively impact patient outcomes. The ideal interval between final cross-sectional imaging and liver resection for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) is not well established.The aim of the study was to explore the most appropriate interval between scan and operation and its effect on outcomes; Tumour growth, resectability, R0 rates, disease free survival and overall survival.

Methods

A retrospective analysis of our prospective maintained liver resectional database was performed. Patients undergoing resection for HCC or CRLM between January 2020 and December 2021 were included. Patients were followed up until June 2023. Groups were split into a <6-week interval and ≥6-week interval group. Scans and radiology reports and post-op histology were reviewed to identify interval changes of individual tumours. We analysed outcomes of gross and percentage increase in tumour size, recurrence rates, median disease-free survival and overall survival. Patient demographics including age (≥18), gender, BMI, neoadjuvant chemotherapy, type of scan, initial size and number of lesions were analysed.

Results

53 patients were included in the analysis (19 female). Disease free survival was 27.4 months in <6 week group vs. 24.9 months in ≥6 week group. Average tumour growth was 5.9mm higher (range 3.7-9.6mm) when interval time was >6 weeks. Tumour percentage growth was 11.5% in <6 week group vs 32% in ≥6 week group. Recurrence rate in <6 week group was 23.5% VS 30.5% in ≥6 week group. There was no difference in percentage overall survival, non-resectability rate or R1 rates.

Conclusions

In this snapshot study of liver resections over a two-year period we did find an expected bigger increase in tumour size in patients where the interval between last cross-sectional imaging and actual resection was longer. The ≥6week interval group seems to have more tumour recurrence but this did not impact overall survival. This pilot cohort was not powered to firmly establish guidance for maximum interval between last scan and surgery, but it prompts further investigation to get clarity to guide clinical practice. A larger cohort would ideally look at HCC and CRLM separately.
HPB P36 Good Medical Practice: Patient's right to the information - An audit of the patient's understanding and satisfaction with the information provided to the patients with acute pancreatitis
Authors: Khawaja Zeeshan , Jamal Zohaib , Zafar Nowera , Adnan Naqqash
Published: November 2023

Background

Acute pancreatitis is one of the important and common causes of abdominal pain presenting to the emergency surgical take. The incidence of pancreatitis in the UK is approximately 56 cases per 100,000 people per year. Due to variation in the causes, disease course, investigations and treatment, it may be confusing for the patient to fully understand all the information. NICE guidelines and good medical practice recommends ‘to give people with pancreatitis, and their family members or carers (as appropriate), written and verbal information in a way they can understand’.

Methods

The aim of this audit was to find out if adequate information as per the NICE guidelines was being provided to the patients and their family members, and to assess patients’ satisfaction in terms of the provided information. 30 patients who were admitted in the department of general surgery with acute pancreatitis were provided with a questionnaire containing 10 questions asking about the information provided to them about their condition by the healthcare professionals. At the end of the first cycle an intervention in the form of following leaflet was introduced and a re-audit was done:  

Results

Overall, 60% of the patients were not satisfied with the information provided. None of the patients was provided written information and more than 90% were not explained condition with the help of a diagram. The other areas where the patients were not provided information were: investigations done (40%), treatment (60%), provision of verbal information (26%) and alcohol as the potential causes of the condition (27%). A re-audit was done the results of which are compared with the first cycle below:

Conclusions

This audit emphasized the need of a proper explanation of acute pancreatitis to the patients and their family members. It was also found that no leaflets were available for the patients. Results were shared in the surgical team group and a leaflet has been designed and distributed to every patient with acute pancreatitis.

Second Cycle: After the introduction of the leaflet, improvement has been seen in almost all the areas of the information provided to the patients. Overall, satisfaction has improved from 60% to 92% in the patients admitted with acute pancreatitis.
HPB P38 A Novel Ambulatory Pathway in the Management of Acute Pancreatitis
Authors: Fox Benjamin , Walters Mary , Peckham-Cooper Adam , Blencowe Natalie , Pathak Samir
Published: November 2023

Background

The incidence of acute pancreatitis has doubled over the last two decades, accounting for approximately 20,000 UK inpatient admissions yearly1. The Atlanta Classification defines three severity grades, with over 90% of patients “mild” or “moderate” severity2,3. Validated risk-stratification tools including the Harmless Acute Pancreatitis Score(HAPS), supported by NEWS score, and biomarkers including CRP, predicts up to 97% of patients who will run a “mild” disease course; and are therefore suitable for ambulatory care4. Currently, however, these ambulatory pathways don’t exist. The main aim of the study was to develop a safe ambulatory pancreatitis pathway to reduce hospital admissions.

Methods

The study consists of four phases. Phase 1 involved development of an evidence-based, safe ambulatory pathway, based on HAPS and augmented with clinical/biochemical predictors of severe disease, complications, or mortality (See Figure 1). Phase 2 involved a 4-week retrospective analysis of all patients presenting with acute pancreatitis using the evidence-based pathway described above. Subsequent Atlanta classification, as well as documentation of complications/requirement for escalated care confirmed suitability for ambulatory care. Phase 3 is currently underway and involves piloting the pathway, and Phase 4 will consist of refining the pathway based on clinical, economic outcome measures and stakeholder views.

Results

Phase 1: Following literature review, use of HAPS, a CRP>100, neutrophils>15x109/l and NEWS of 2 or more, were identified as the most reliable severity scoring tools in acute pancreatitis. NEWS of 2 or more is an independent predictor of increased complications and resultant mortality. CRP and neutrophilia both have 90% sensitivity in predicting a severe disease course.

Phase 2: 27 confirmed cases of acute pancreatitis were identified. Of these, five (alcohol-related in 3 and gallstone-related in 2) met the criteria for ambulatory care. Mean hospital stay was 6 days: no patients died, and none required escalation from ward-based care.

Conclusions

This retrospective analysis has shown that almost a fifth of patients with acute pancreatitis, admitted on the acute on-call take, could be managed in an ambulatory fashion as per currently established severity scoring criteria. Development of the ambulatory acute pancreatitis protocol required an integrated approach from key stakeholders including the emergency general and pancreatic surgical teams and ambulatory care staff. Further prospective analyses of the pathway will be required to identify its patient-reported satisfaction and economic benefits.
HPB P39 Pre-operative Cardiopulmonary Exercise test as a Predictive tool for post pancreaticoduodenectomy intra-abdominal collection development. A Retrospective study
Authors: Hassan Ahmed , Taggarsi Meghana , Chong Thomas , Sultana Asmaa
Published: November 2023

Background

Cardiopulmonary Exercise Test (CPET) provides a non-invasive assessment tool for physiological fitness and peri-operative mortality in major abdominal surgery including Pancreaticoduodenectomy (PD). Post-operative complications including intra-abdominal collection could potentially delay adjuvant chemotherapy following PD. There is minimal evidence in the literature to link CPET derived variables to post PD complications. The aim of this study is to evaluate the role of CPET in predicting post operative intra-abdominal collection.

Methods

A retrospective single centre analysis of a prospectively maintained database from 2016 to 2021 for all patients who had PD was performed. Patient demographics, co-morbidities, and CPET variables were collected. Post-operative adverse events including Clavien-Dindo (CD) grade III intraabdominal collection, length of hospital stay and Readmission within 1 year were looked at. P value ≤ 0.05 was considered statistically significant.

Results

143 patients had PD during the study period. CPET was performed in 30 patients (21%). The patients’ age was 67 ±9 (Mean±SD). Forty patients (28.2%) had developed Intra-abdominal collection CDIII. In the CPET subgroup, Anaerobic Threshold (AT) ≤ 14 on CPET was a risk factor to develop intra-abdominal collection CDIII in univariate analysis (60% Vs 9%, Chi2, p 0.02) and multivariate analysis (HR 3.5, 95% CI 1.6-657, p 0.02). Another significant risk factor was a post-operative pancreatic leak (POPF) (40% Vs 22%, Chi2, p 0.04).

Conclusions

Patients who have Anaerobic Threshold ≤ 14 on CPET, are more likely to develop intra-abdominal collection requiring drainage after Pancreaticoduodenectomy. This group of patients will be less likely to start chemotherapy early.
HPB P40 Laparoscopic spleen-preserving distal pancreatectomy versus laparoscopic distal pancreatectomy with splenectomy: A systematic review and meta-analysis
Authors: Ghassemi Nader , Hajibandeh Shahin , Hajibandeh Shahab , Romman Saleh , Laing Richard , Bhatt Anand , Athwal Tejinderjit , Durkin Damien
Published: November 2023

Background

To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

Methods

A systematic search of electronic databases and bibliographic reference lists were conducted. All comparative studies reporting outcomes of IS and CS in hepaticojejunostomy and choledochocholedochostomy were included and their risk of bias were assessed using ROBINS-I tool. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters.

Results

Ten comparative studies (2 prospective and 8 retrospective) were included which reported 1617 patients of whom 1186 patients underwent Roux-en-Y hepaticojejunostomy (IS:789, CS:397) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS:168, CS:263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD:14.15 minutes, p=0.0002) compared to CS, there was no significant difference in overall biliary complications (OR:1.34, p=0.11), bile leak (OR:1.64, p=0.14), biliary stricture (OR:0.84, p=0.65), cholangitis (OR:1.54, p=0.35), or liver abscess (OR:0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in all categories compared to CS.

Conclusions

Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable clinical outcomes. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high-quality research is encouraged to report the outcomes with respect to duct diameter and suture material.
HPB P45 Assessment of quality of documentation for Laparoscopic cholecystectomy: a quality improvement project
Authors: Saeed Aziz Sarmad , Ibrahim Shalaby Amr , Mohamed Mohamed Saleem Noor , Khan Sumbel , Darrien Jennifer
Published: November 2023

Background

Laparoscopic cholecystectomy is one of the most common procedures carried out in a General Surgery unit both in emergency and elective theatres. Getting It Right First Time (GIRFT) and the Royal College of Surgeons England (RCS) have made best practice recommendations to ensure adequate documentation of laparoscopic cholecystectomy operation details for good clinical communication with colleagues and to aid in the review of operations after a patient complaint. This is a Quality Improvement Project (QIP) in a NHS Trust in West Midlands to assess the quality of documentation in view of the recommendations made by GRIFT and RCS.

Methods

Documentation including operative note, clinical noting, ward round entries, laboratory results, imaging records and clinical letters were reviewed for 100 consecutive laparoscopic cholecystectomies carried out during the month of May 2023 and assessed against a checklist based on recommendations made by GIRFT and RCS. Following the audit, a multifaceted intervention is planned, including teaching presentations and an electronic documentation template. A re-audit following interventions will be carried out in July, 2023.

Results

There was mixed compliance with GIRFT recommendations. Some recommendations, including indication for surgery, consent, WHO checklist, and surgeon details were followed in all cases. Documentation shortcomings included missing details on technique for pneumoperitoneum with 19% of operation notes failing to mention this detail ,intraoperative drug administration (54%), intraabdominal pressure levels (95%), Number of clips applied (66%), gall bladder retrieval method and port used for the purpose (38%), confirmation of port removal under vision (32%), hemostasis achievement (12%), fascia closure (26%), critical view of safety/safe view assessment (49%), anesthetist names (62%), and first surgeon's signature (41%).

Conclusions

We found significant shortcomings in documentation of patients undergoing laparoscopic cholecystectomy. This documentation needs improvement and standardization so that it meets the GIRFT and RCS Guidelines.
HPB P47 Torsion of a wandering gallbladder
Authors: Marchese Salvatore , Samra Benjamin , Bond-Smith Giles
Published: November 2023

Background

Gallbladder torsion is an uncommon cause of acute abdomen. Despite over 500 reports published since 1898, only 10 cases of wandering gallbladder have been reported.

In this anatomical variant (4-5% of the population) the gallbladder has no attachments to the liver. It is suspended only by the cystic duct and artery, which predisposes to twisting of the pedicle. Subsequent gallbladder necrosis can lead to rupture, peritonitis, sepsis and death (6%).

Patients are typically elderly females, above the age of 70. A palpable gallbladder is described in 54% of cases. We report a rare case of wandering gallbladder leading to torsion.

Methods

An 89-year-old lady presented to emergency department with abdominal pain associated with vomiting and bowel not opened for five days. A palpable mass was evident on the right lower side of her small abdomen.

Vital signs and lactate level were within normal range. Despite CRP was only moderately elevated on admission, it suddenly climbed to 504 within 24 hours.

An abdominal CT scan showed a distended thick-walled gallbladder with a large stone, reported as “consistent with chronic calculous cholecystitis”.

Results

The patient was urgently brought to theatre for a laparoscopy where a free-floating gallbladder was found at the right lower quadrant, distended and gangrenous, rotated around its vascular axis.

The surgery was converted to open due to lack of sufficient intra-abdominal space to accomplish the procedure. Her gallbladder was in the end successfully removed with no further concern and a washout of the peritoneal cavity was performed.

The subhepatic drain was removed on day 1 postoperative. She recovered uneventfully and was discharged 12 days later due to social issues.

Conclusions

Despite rarely encountered, gallbladder torsion should be considered in the differential of patients presenting with acute abdomen, especially in case of rapid deterioration.

Symptoms are nonspecific, as well as radiographic signs. A preoperative diagnosis is rarely made. If delayed, the condition may potentially become life-threatening.

Surgical exploration is thus warranted and, once recognized, cholecystectomy remains the only resolutive treatment.
HPB P48 Liver Abscess Secondary to Cocktail Stick Migration Following Accidental Ingestion
Authors: Attard Joseph , Das Debashish , Mullineux Joseph , Bhardwaj Neil
Published: November 2023

Background

Liver abscess formation following foreign body ingestion is rare. This may occur if the foreign body is lodged in the upper gastrointestinal tract and persists. Initial management consists of antibiotics with or without percutaneous abscess drainage. However, referral to the regional HPB unit may need to be considered to discuss foreign body retrieval, especially if it is located within the liver parenchyma itself, in order to treat persistent sepsis or prevent abscess recurrence in the future.

Methods

A 38-year-old gentleman, previously healthy, presented to the emergency department of a district general hospital with nausea, upper abdominal pain, and fever. He stated that he had accidentally ingested a piece of a wooden cocktail stick while eating some weeks back. Leucocytosis and raised inflammatory markers were present on bloodwork. Computed tomography revealed a 6 cm hypoattenuating lesion in the left lobe of the liver, which demonstrated features of a hepatic abscess on magnetic resonance imaging. Abdominal ultrasound visualised a 4 cm linear hyperechoic structure within the hypoechoic lesion, raising the suspicion of foreign body retention with abscess formation.

Results

The fever subsided, and symptoms resolved with antibiotics. Follow-up imaging revealed abscess resolution with foreign body persistence in the liver. He was referred to the regional HPB unit and underwent laparoscopy for foreign body removal. A fistulous communication between liver segment II and lesser curvature of the stomach was seen and disconnected using diathermy. Minimal pus was drained and the foreign body retrieved. The gastric perforation was sealed using a linear stapling device. A nasogastric tube was left in the stomach until the patient tolerated a liquid diet and discharged on the first post-operative day. He remains well on follow-up.

Conclusions

This case highlights that scrupulous history taking and imaging review are required for a timely diagnosis of foreign body retention.
HPB P49 Implementation of a standardised operation note template using the Getting It Right First Time (GIRFT) and Royal College of Surgeons of England (RCS) best practice guidance to improve the quality of laparoscopic cholecystectomy documentation
Authors: Goulder Lewis , Daniels Sarah
Published: November 2023

Background

Getting it right first time (GIRFT) in partnership with the Royal College of Surgeons of England (RCS) have published advice on aspects of surgery which should be documented in the laparoscopic cholecystectomy (LC) operation record. This is following calls to enhance the accuracy and value of operative records coupled with a lack of existing recommended minimal standards. Operation notes are fundamental for communication of patient care and in the review of operations following adverse events or patient complaints.

Methods

We reviewed 20 operation notes to assess adherence to the guidance. Some aspects of the guidance were omitted if expected to be documented elsewhere in the patient records, 28 of 32 points were reviewed. An operation note template was created and implemented then a further 20 operation notes were reviewed.

Results

Initially, the mean completeness of guidance items was 39%. 6 of the 20 operation notes documented that the ports were inserted under direct vision; 8 documented that a critical view of safety was achieved; 13 documented the spillage/non spillage of bile or stones; 16 documented removal of ports under direct vision and none included all aspects of the post-operative plan. Following implementation of the template, compliance improved across all items.

Conclusions

There is scope to improve the documentation of LC, particularly in areas linked to common intraoperative and postoperative complications. Implementation of a standardised operation note template is an effective way of improving the documentation of laparoscopic cholecystectomy.
HPB P53 Readmission rate after laparoscopic cholecystectomy in a tertiary HPB Unit
Authors: Scoffield Julie , Dorrian Emmet , Kirk Gareth
Published: November 2023

Background

Laparoscopic cholecystectomy comprises a large portion of benign biliary surgery, and is increasingly performed safely as a daycase. The aim of our study was to determine the rate of unplanned readmission to hospital or unscheduled contact with medical services following discharge after laparoscopic cholecystectomy, along with the reasons for seeking medical advice.

Methods

Patients were identified retrospectively from our HPB Unit's operative database. All patients were included (daycases and inpatients) who underwent laparoscopic cholecystectomy in our unit in the calendar year 2019. Patients were excluded if they also had a CBD Exploration, or if their operation was converted to an open procedure. All patients' records were reviewed in detail on the Northern Ireland Electronic Care Record to capture readmissions, A&E attendances and contact with Out of Hours GP service within 30 days of discharge from hospital following operation.

Results

273 patients were admitted for planned cholecystectomy under 7 Consultant Surgeons. 257 had their operation completed laparoscopically (5.86% conversion rate). The overall daycase rate was 66%. 39 patients (15%) sought unplanned medical advice within 30 days of discharge. 15 patients (5.8%) contacted Out of Hours. A further 9 patients (3.5%) went to A&E. Most of these had pain or wound problems. There were 15 (5.8%) readmissions to hospital: 3 within 48 hours; with abdominal wall haematoma, constipation and pneumonia. The remainder (day 4-29) had mostly pain, vomiting or umbilical wound infection. Median length of stay was 3 days.

Conclusions

Our early readmission rate was low and in line with local guidance of <10%. Most patients seeking unplanned advice had pain or wound problems. Further work looking at counselling patients regarding postoperative pain and wound care may reduce the total readmission rate and unscheduled contact after discharge. Readmission was not dependent on the age or size of the patient, or on whether the operation was carried out as a daycase or inpatient.
HPB P55 An audit of the quality standards for Laparoscopic Cholecystectomy. Compliance with the AUGIS standards (AUGIS: Association of Upper Gastrointestinal Surgery of Great Britain and Ireland)
Authors: Khawaja Zeeshan
Published: November 2023

Background

Laparoscopic cholecystectomy, which is a minimally invasive operation, is one of the most common surgical procedures in the UK and worldwide. Indications for LC include acute or chronic cholecystitis, symptomatic cholelithiasis, biliary dyskinesia, acalculous cholecystitis, gallstone pancreatitis, and gallbladder masses or polyps. The purpose of this audit was to assess and compare the outcomes after LC with the standards published by the association of upper GI surgeons (AUGIS) and to formulate measures to improve services at Royal Albert Edward Infirmary.

Methods

A data of 56 patients who underwent cholecystectomy was analysed retrospectively by two different auditors. All patients who underwent both open and laparoscopic cholecystectomies were included in this study.

Results

Our results showed that the majority of the patients (40/56) were females. Only 3 patients had open cholecystectomy while the rest of the 53 patients had LC. 67% (38/56) were done as a day case and discharged home the same day after surgery. None of the patients had an emergency and thus timely management of the disease in terms of surgery within the first 7 days of presentation. 7/56 patients were readmitted with different complications. No bile duct injuries were recorded.

Conclusions

Our hospital was found out to be compliant with only ⅙ criteria assessed. This study concludes that there is a need to improve outcomes in all domains especially the easily reversible factors such as day case rates and readmission due to complications.
HPB P56 Service Evaluation of Hot Gall bladder Pathway
Authors: Muhammad Ahmad Muhammad Salah , Ramzy Elmaradny Ahmed , Mourad Moustafa
Published: November 2023

Background

Management of acute cholecystitis has traditionally been conservative. Initially patients are treated with antibiotics posted for LC after 4-6 weeks.Surgery during acute settings was previously avoided due to fear of injuring surrounding structures. NICE guidelines published in October 2014 now advises that patients presenting with acute cholecystitis should have LC within a week which has been proven to be safe and effective. With respect to acute pancreatitis the standard of care should be lap chole during index admission for all non-severe cases. The purpose of this study is to evaluate the management of patients admitted with acute gall stone diseases.

Methods

It was a retrospective study of all the patients admitted with acute gall stone diseases and compare the outcomes after introduction of Hot Gall Bladder Pathway.

We screened a total of 245 patients who had been included in this study between October 2018 to March 2020 with two groups:

Data were collected form EZ Notes,IT Systems,Databases,Observations and Paper Records.

Results

Acute cholecystitis with no associated organ dysfunction who underwent Laparoscopic Cholecystectomy within week of diagnosis in the pre Hot GB List period was 43%(31/74) wheras in the Post Hot GB List period was 81% (93/116). Mild Acute Biliary Pancreatitis who underwent LC within index admission was 30% (5/17) in the preHot GB List Period wheras 78%(14/19) of patients with gall stone pancreatitis under went LC during the same admission after the beginning of Hot GB lists.        

Conclusions

We had achieved almost 81% of the expected outcome in surgically dealing with patients presenting with acute cholecystitis and 78% with patients presenting with gall stone pancreatitis after introduction of Hot Gall bladder pathway. Safe and cost-effective hot gall bladder service can be provided by the EGS with input from upper GI surgeons with acceptable morbidity and a satisfactory outcome. Hot gall bladder pathway has proven to be effective in treatment of GS related diseases without significant increase in complication rate. It also helps avoiding readmissions, Gall stone related complications, reduces bed occupancy and improves patients’ quality of life.
HPB P57 Outcomes of Transarterial Chemoembolization (TACE) at East Lancashire Hospitals NHS Trust
Authors: Zafar Nowera , Jamal Zohaib , Sultana Asma
Published: November 2023

Background

Hepatocellular carcinoma (HCC) accounts for 85%–90% of all primary liver cancers and is a significant cause of morbidity and mortality worldwide. The aim of this study was to evaluate the efficacy and safety of the procedure at ELHT. TACE is an image-guided IR locoregional therapy for unresectable hepatocellular carcinoma patients to improve their survival. It has emerged as an efficacious palliative option for inoperable cases as it is less invasive and known to have fewer complications. It may also act as a bridge for liver transplantation.

Methods

This is a retrospective study with data collected over 2 years. Treatment-naive patients aged 18 and above with unresectable HCC with a Child-Pugh Class A/B were selected. Treatment response was assessed after every TACE session using CT or MRI within 6 weeks of TACE, according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Safety was assessed based on technical success and the number of complications.

Results

35 patients underwent TACE (median age - 79). The commonest underlying etiologies were liver cirrhosis (25%) and alcohol (22%). Of the total 90 sessions, partial response was seen in 44% (39 sessions) followed by complete response in 23% (21). For 22% (20), the outcome was stable disease. Since 74% of the patients had multiple sessions, efficacy per patient showed a result of complete response in 44% and partial response in 18%.1 year survival rate was 60%, 21% had a recurrence and 22.8% developed complications (3 liver abscesses). The technical success achieved was 97.7%.

Conclusions

TACE is safe and effective for treating HCC patients, who are unsuitable for thermal ablation or surgery as it offers comparable survival benefits. ELHT showed a successful disease control (complete, partial response + stable disease) of 89% through TACE. Liver abscess was the commonest compilation in our study (22%) - this was higher when compared with the existing literature (an average of approximately 6%).
HPB P60 Satisfaction Rates with Telephone Follow-Up Clinic Appointments
Authors: Murugan Veylamuthen , Wong Tiffany , Fouad Mina , Sanyal Sudip
Published: November 2023

Background

Since the onset of the COVID-19 pandemic, telephone follow-up (TFU) clinics have become an integral part of delivering healthcare. Advantages of telephone clinics include reducing costs and increasing efficiency. This quality improvement project (QIP) was conducted to evaluate patient satisfaction rates with hepato-pancreato-biliary (HPB) telephone follow-up clinic appointments and improve those rates.

Methods

The Likert-scale is a 13-item questionnaire tool ranging from 1-5 (1=strongly disagree, 5=strongly agree) and was used to assess patient satisfaction with TFUs, both before and after implementation of measures for improvement. Satisfactory cut-off point (score of 4) was analysed across all responses. Retrospective questionnaires were completed for 100 patients pre-interventions, and for 42 patients post-interventions. All patients were verbally consented. Presentation of initial findings and education surrounding areas to be improved at a departmental meeting, and use of a structured teleconsultation template were the measures implemented for improvements. Outcomes included overall satisfaction rates across gender and age groups.

Results

The overall satisfactory rate with TFUs improved from 75% to 95.2%. When analysed according to sex, the satisfactory rates improved for males from 67.6% to 91.7%, and for females from 79.4% to 96.7%. As for satisfactory rates according to age, improvements were noted in 3 out of the 4 pre-determined age groups; <50 years improved from 72.2% to 100%, 50-59 years declined from 88.9% to 80%, 60-69 years improved from 71.4% to 100% and >70 years improved from 72% to 93.7%.

Conclusions

Initial findings were positive but there was still room for improvement. The 2 main interventions used were discussion and teaching in a departmental meeting, and the implementation of a teleconsultation template. Implementation of these measures were successful in significantly improving the satisfactory rates with TFUs.
OGC P02 Neutrophil/lymphocyte ratio and long-term survival after pancreatoduodenectomy for malignancy
Authors: Arain Zohaib , Alghazawi Laith ,   RAW Study Collaborators, Fehervari Matyas , Spalding Duncan
Published: November 2023

Background

Previous authors have highlighted that preoperative neutrophil/lymphocyte ratio (NLR) may be of prognostic importance in patients who undergo pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC), ampullary carcinoma (AA) or cholangiocarcinoma (CC) of the pancreatic head/periampullary region. Various cut-off thresholds have been suggested. This study aimed to compare the five-year survival rates of PD patients with high preoperative NLR to those with low preoperative NLR (using thresholds from recent studies).

Methods

Data was 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 were grouped by their underlying cancer type and divided into “high NLR” (PDAC: ≥ 3.74, AA: ≥3.0, CC: ≥2.75) and “low NLR” (PDAC: <3.74, AA: <3.0, CC: <2.75) groups. Five-year survival rates were compared using Fisher’s exact test.

Results

Out of 1484 patients, 885 (59.6%) had PDAC, 394 (26.5%) had AA and 205 (13.8%) had CC, and NLR was available in 88.4%, 89.1% and 92.2% of cases, respectively. The median NLR was 2.7 (range: 0.1-34.0), 2.8 (range: 0.3-103.0) and 2.7 (range:0.1-83.3) for patients with PDAC, AA and CC, respectively. Low NLR did not correlate with improved five-year survival rates in any of the studied cancers (PDAC: 24.5% vs 23.8%, p=0.9, AA: 56.1% vs 51.2%, p=0.4, CC: 34.4% vs 25.8%, p=0.2).

Conclusions

In our multicentre study of PD outcomes, preoperative NLR was not useful for predicting five-year survival in patients with PDAC, AA or CC.