bluuebunny/crossref_metadata_2025 huggingface dataset:
P-OGC74 Effect of pre-operative anaemia on short-term outcomes following oesophagectomy: a 10-year retrospective cohort study
Authors: Chien Siobhan , Khan Khurram , Gall Lewis , Deboys Liam , Craig Carol , MacKay Colin , Macdonald Andrew , Forshaw Matthew
Published: December 2021

Background

Pre-operative anaemia is associated with increased length of hospital stay, requirement for allogenic blood transfusion, post-operative complications and mortality. Oesophagectomy is a complex procedure associated with significant physiological insult, thus pre-operative patient optimisation is imperative to improve clinical outcomes. This study aimed to determine the impact of pre-operative anaemia on short-term outcomes following oesophagectomy for benign and malignant disease. 

Methods

A retrospective cohort study of all oesophagectomies performed in a single tertiary referral centre between 1 January 2010 and 31 December 2019 was performed. Patients were identified from a prospectively collected database and individual patient electronic records were interrogated. Patients were dichotomised into two groups, based on the most recent pre-operative haemoglobin. Patients with pre-operative anaemia (haemoglobin <130mg/L in males and <120mg/L in females) were compared to those without pre-operative anaemia. Patients with missing data were excluded from the study. Patients were followed up for a median of 32 months (IQR 18-66).

Results

Of 352 patients eligible for inclusion, 173 (49.1%) patients were anaemic immediately pre-operatively. Patients with pre-operative anaemia were older (66 vs. 64 years, p = 0.031), with a lower anaerobic threshold (11.7 vs. 12.3ml/min/kg, p = 0.011), and were significantly more likely to have undergone neoadjuvant chemotherapy (91.3% vs. 78.8%, p < 0.001). Patient comorbidities and disease-related characteristics were similar between the two groups. Patients with pre-operative anaemia were significantly more likely to require post-operative blood transfusion (34.7% vs. 16.8%; p < 0.001). However, pre-operative anaemia was not associated with increased post-operative complications, intensive care admission, length of hospital stay, or 30- and 90-day mortality rates following oesophagectomy.

Conclusions

Patients with anaemia immediately prior to undergoing an oesophagectomy were significantly more likely to require post-operative blood transfusion. However, pre-operative anaemia was not associated with an increased rate of post-operative morbidity or mortality. In addition, pre-operative iron transfusion is becoming increasingly utilised to minimise the incidence of pre-operative anaemia: this was not analysed in this study.
P-OGC81 The learning curve for robotic assisted abdominal phase in two stage oesophagectomy
Authors: McQuillan Patrick , Ahmed Salman , Navidi Mazair , Wahed Shajahan , Immanual Arul
Published: December 2021

Background

Robotic assisted oesophagectomy (RAO) is increasingly being utilised in the management of oesophageal cancer. RAO implementation into practice has an inevitable learning curve. As oesophagectomy usually involves at least 2 stages, a staggered approach to training and introduction of RAO can be done. A major advantage of this is that the surgeon can concentrate on overcoming the learning curve in one phase of the procedure at a time, whilst the remaining phase can be completed by an established technique.

This study looks at the learning curve of a robotic assisted abdominal phase for two-stage oesophagectomy compared to an open abdominal phase to achieve parity.

Methods

This study uses a prospectively maintained database to retrospectively analyse the abdominal phase of the first 17 RAO compared to the previous 20 open abdominal phase procedures. The cases are sequential, done by a single surgeon at a large UK oesophagogastric referral centre. Operating time, nodal count, and R0 rate were reviewed to determine the number of cases on the learning curve to reach parity with the open procedure.

Results

The open abdominal phase group had a similar age (65.6 vs 65.7), pre-op anaerobic threshold (13.9 vs 14.6 p = 0.3) but a higher BMI (mean 30.6 vs 24.6 p < 0.05) then the RAO group. All cases were T3 adenocarcinoma except for 2 cases in the robotic group (one HGD and one T2 adenocarcinoma). No RAO cases were converted to open. The mean time for the abdominal phase in the open group was 175.4 minutes with an average nodal count of 32.9. After 8 robotic assisted cases the mean operating time decreased from 267 minutes to 197 minutes, which was when a non-significant difference to the open group (p = 0.094) became apparent. The mean nodal count in the first 8 robotic assisted cases was 29.5 and increased to 38.4 in the subsequent cases. All patients had a R0 resection.

Conclusions

The multi-phase nature of oesophagectomy allows for modular implementation of a robotic programme. We have found that the learning curve for robotic assisted abdominal is around 8 cases. This allows for parity to open abdominal phase to be achieved regarding operative time, nodal count and R0 resection.
P-OGC83 The Impact of Covid-19 on Malignant Upper GI Operations in England During 2020
Authors: Sandland-Taylor Laura , Jenkins Barbara , Beckingham Ian
Published: December 2021

Background

Due to the Covid-19 pandemic and the overwhelming number of patients requiring ITU due to serious Covid-19 infections, trusts throughout England reduced their operation numbers to reduce the burden on secondary care services. Whilst efforts were made to preserve cancer services in England, the Covid-19 burden still significantly impacted the provision of oesophagectomies and gastrectomies. The following research aims to look at the true impact of Covid-19 on operation numbers in England and compare these to the Covid-19 burden. 

Methods

Data relating to operation numbers was taken from The Surgical Workload Outcomes Audit (SWORD) database. The SWORD database was interrogated for the years 2017 – 2020. A mean number of operations was calculated using the 2017-2019 data and compared to data from 2020. Operations performed and other demographic data  was analysed regionally and compared to Covid-19 deaths throughout England. Covid-19 data was obtained from the national government dashboards. 

Results

Results showed that there was a significant reduction in the number of operations performed in 2020 due to the Covid-19 pandemic. This was closely correlated with Covid deaths throughout England. Variations between centres were present throughout the UK, however the overall trend reflected more than a 40% reduction in gastrectomies and more than a 30% reduction in oesophagectomies, which equated to 1018 less gastrectomies and 490 less oesophagectomies performed in 2020. There was significant variation between centres, the impact on individual centres and oesophagectomy rates ranged from -0.8% reduction to a 100% reduction in operations carried out in 2020. Gastrectomies was similarly affected, varying between a 2.7% and 89.5% reduction in operations carried out in 2020. 

Conclusions

Overall, despite efforts to preserve procedures, particularly for malignant disease, there was significant fall in operations performed throughout 2020. As a consequence of this, it is likely that patients requiring life saving or life extending operations did not receive their treatment. The data suggests that overall gastrectomies were worse hit than oesophagectomies across England. Variances in performance across the UK should be further analysed to allow better planning and resource allocation for future waves or future pandemics.
P-OGC88 Is Routine Contrast Swallow after Ivor-Lewis Oesophagectomy Required or Justified?
Authors: Mukhopadhyay Ishani , Krishnamoorthy Ashwin , McLaughlin Euan , Menon Vinod , Tan Lam Chin , Nilanjana Tewari
Published: December 2021

Background

Traditionally many Upper-GI cancer tertiary centres have carried out contrast swallow fluoroscopic studies as a routine after Ivor-Lewis “Two-Stage” Oesophagectomy. However, more recently studies have demonstrated the limited value of this test as a routine screening study. The primary outcome of our study was to assess the sensitivity of routine contrast swallow in identifying anastomotic leak post oesophagectomy and identify how the study changed management of these patients. 

Methods

This was a single-centre retrospective study involving 2-observer data collection. Data was collected and analysed from clinical notes for all patients who underwent an Ivor-Lewis oesophagectomy for cancer between January 2011 to December 2020.

Results

A total of 220 patients were identified. Protocol at the centre was to obtain a routine contrast swallow in the Fluoroscopy department on the fifth post-operative day– which occurred in 211 patients (96%). A total of 19 (8.64%) patients were diagnosed with an anastomotic leak (clinically and/or radiologically), with contrast swallow imaging and/or computed tomography (CT). There was no correlation between incidence of leak and T stage (p = 0.38) and N staging (p = 0.22). 

Only 3 of 19 anastomotic leaks were positively identified on contrast swallow study. All patients with anastomotic leak identified by contrast swallow study were asymptomatic i.e. “subclinical”. 2 patients were managed conservatively; one underwent endoscopic stent insertion. CT scan with oral contrast was the mode of diagnosis for 16 anastomotic leaks; where 10 patients underwent a CT scan following a normal contrast swallow study due to suspicious symptoms and 6 patients underwent expedited CT scans prior to Day-5 contrast swallow study due to presence of symptoms and limitation of fluoroscopy resources. The sensitivity of the Day-5 contrast swallow study was calculated to be 15.8% (CI 3.4, 39.6) with a specificity of 98.0% (CI 95.0, 99.5). 

Conclusions

Our data reflects that routine contrast swallow study on Day-5 post Ivor-Lewis esophagectomy has a poor sensitivity in detecting anastomotic leak and may be falsely reassuring. The vast majority of patients had no change in management as a result of contrast swallow. 

This adds to the growing body of evidence limiting the role of contrast swallow in this situation. We recommend that clinical judgement and use of CT and endoscopy be the surgeon’s prime tools in the diagnosis of anastomotic leak post oesophagectomy.
P-OGC90 Hiatus Hernia post oesophagectomy for oesophageal cancer: incidence & outcomes
Authors: Askari Alan , Wheat Jennifer , Kangatharan Chrishthuka , Ismail Mouhamad , Gourgiotis Stavros , Safranek Peter , Sujendran Vijayendran , Hindmarsh Andrew , Bennett John , Hardwick Richard , O'Neill Robert
Published: December 2021

Background

The development of a hiatus hernia following oesophagectomy is a well-documented occurrence. The aim of this study is to examine the incidence of hiatus hernia formation, the symptoms patient present with and differences between open and laparoscopic/minimally invasive surgery.

Methods

A dataset containing data on all patients from an upper GI regional tertiary referral centre were analysed. All subsequent patients who underwent oesophagectomy between Nov 2014 and Nov 2020 were included.

Results

A total of 268 patients underwent oesophagectomy over this time, of whom 81.0% (n = 217/268) were male and the median age was 68 years old (62-73 years). The median BMI at the time of operation was 27.6Kg/m2 (IQR 24.6-30.7Kg/m2). Over a median follow up of 12 months (IQR 5-21), 4.5% (n = 12/268) developed a hiatus hernia. Amongst these 12, the most common organ in the hernia was the transverse colon (66.7%, n = 8/12) and the small bowel (n = 3). The most reported symptoms in those with a hiatus hernia were respiratory symptoms (cough/breathlessness: n = 5), reflux (n = 3), vomiting (n = 3) and chest pain (n = 3). There was no correlation between BMI and the occurrence of a hiatus hernia (p = 0.145) nor were there differences across males and females in terms of hiatus hernia rates (p = 0.845). In patients who had prophylactic repair of the diaphragm (n = 126/268, 47.0%) the rate of hernia repair was no different (4.8%) compared with those who did not have a prophylactic diaphragmatic repair with sutures (4.2%, p = 0.832). There was however a correlation between the volume of intraoperative blood loss and the occurrence of a hiatus hernia, with increasing blood loss correlating with a higher likelihood of hernia occurrence (r = 0.295, p = 0.037).

Conclusions

Hiatus hernia is a relatively common occurrence after oesophageal cancer surgery, with most patients suffering from chest symptoms, pain, and reflux. Intra-operative blood loss may influence the chances of developing a hiatus hernia. Prophylactic measures such as reinforcing the diaphragm or hiatus with sutures, do not appear to affect hernia rates.
P-OGC92 Esophagogastric Lymphomas; Lymphomas outside Lymphoid tissue
Authors: Younus Hafsa , Thomas Joel Joy , Siddiq Faateh , Sharma Vishali , Fiyyaz Sadaf , Mukherjee Dipankar , Mukherjee Samrat
Published: December 2021

Background

Primary gastric lymphomas are rare tumours and account for 5% of all gastric neoplasms. Esophaphageal lymphomas are even rarer, accounting for 1% of all oesophageal tumours. Incidence of these tumours have been increasing over time and there is increasing need to understand this tumour subtype. This is a single centre study of esophagogastric lymphomas over a period of 15 years.

Methods

Between 2005 to 2020; patients who were diagnosed of having esophagogastric lymphomas, were retrospectively studied. Their clinical records were assessed for age, gender, clinical signs and symptoms, histological type, association with H pylori, LDH levels, stage at diagnosis, treatment type, Endoscopy and clinical follow up and survival.

Results

66 patients were diagnosed of having lymphoma, out of which 4 (6%) were oesophageal and 62 (93.93%) were gastric. Median age was 77 years (Range 41-102 years), 39 were male (59%) and 27(41%) were female. Anaemia was the commonest sign (53%), followed by nausea/vomiting (45%), weight loss (44.5%), abdominal pain (40.6%) and dysphagia (24%). 15.6% patients were found to have H pylori and 10% of patients had Barrett’s. Diffuse Large B Cell Lymphomas were commonest tumours (28.33%) followed by MALToma’s (26.6%). 60% patients were T3/4 at the time of diagnosis and 9.7% had other OG malignancies. 53% patients received antibiotics, 61% received chemotherapy, 16% received chemoradiotherapy and 16% received surgical resection. Median survival was 3 years (range 0-14).

Conclusions

Esophagogastric lymphomas are successfully treated with chemotherapy with promising survival. The stage at diagnosis and presence of comorbidities are limiting factors in overall disease prognosis.
P-OGC96 Oesophagectomy with Enhanced Recovery for Adenocarcinoma in the Elderly
Authors: Adam Mina , Hadjittofi Christopher , Kumar Bhaskar
Published: December 2021

Background

The incidence of oesophageal adenocarcinoma is rising rapidly in high-income countries. Combined with an ageing population, it is expected that the need for treatment, including surgery, will increase in the next decade. Oesophagectomy in patients ≥70 years old has been associated with a higher risk of complications. The aim of our study is to compare the outcomes of patients ≥70 vs < 70 years old, who underwent oesophagectomy for adenocarcinoma with an enhanced recovery (ERAS) protocol.

Methods

A single-centre retrospective study was performed. Eligible cases were divided into the <70 and the ≥70 groups for comparison of baseline variables, postoperative outcomes, and overall survival.

Results

From January 2014 through September 2020, oesophagectomy with ERAS was performed for 230 patients with adenocarcinoma. Most (85%) patients were male. The median age was 70 years. The overall 90-day complication rate was 69.6%. The anastomotic leak rate was 16.1%. The 30- and 90-day mortality rates were 0 and 3.0% respectively. Median length of stay (LoS) was 7.0 days (IQR=5.0) and the readmission rate was 18.7%. The overall complication rate was higher in the ≥70 vs the <70 group (75.6% vs 63.1%; p = 0.038). There was no significant difference in major complications, anastomotic leakage, mortality, LoS, or readmission (p > 0.05) between the groups. Estimated mean survival was lower in the ≥70 vs the <70 group (45.6 vs 57.9 months; p = 0.045).

Conclusions

Elderly patients with oesophageal adenocarcinoma can undergo oesophagectomy with ERAS, achieving similar postoperative outcomes to younger patients. In an era of an ageing population with an increasing disease burden, these findings are encouraging.
P-P04 The cost of acute pancreatitis is amylasing!
Authors: Carr Harry , Morris Timothy , Williams Matthew , Jacob Georgina , Courtney Michael , Kanakala Venkatesh
Published: December 2021

Background

Amylase is the key serum biomarker in the diagnosis of acute pancreatitis, however there is no indication for repeat/serial measurement once the diagnosis is established. It is estimated that £27,000pa is spent unnecessarily on repeat amylase investigations without clinical indication1. 

Anecdotally, within the department, unnecessary repeats were being routinely performed. Resultantly, we audited in 2019 and 2020 to understand the extent of the issue. Following the first cycle, pre-rotation departmental talks were given to all relevant healthcare staff.

Aim(s)

Methods

Data was collected and analysed retrospectively over 2 audit cycles (C1 & C2) from 79 patient episodes of admissions to the surgical department of a Northern Major Trauma Centre with confirmed diagnoses of acute pancreatitis between 01/05/2019 – 31/07/2019 and 01/08/2020 – 31/12/2020. 

Resources used included: patient notes, IMPAX and WebICE.

Data was collected and analysed by one author in C1 but multiple authors in C2.

Results

Mean age = 60 years. 

Male:Female ratio was 8:16 and 24:31, respectively.

Initial amylase was diagnostic in > 75% (61/79).

81 unnecessary repeats performed. 

Most patients underwent imaging (75% and 67%) however, only approximately one-third (30.8% and 32.4%) of scans were performed to confirm the diagnosis.

• Despite imaging confirming the diagnosis in 88%, >50% of imaged patients had repeat amylase testing.

Conclusions

The results demonstrate that our intervention, a pre-rotation departmental talk, has significantly reduced the over-requesting of amylase and current practice is of a good standard. 

Improvements are still required. Resultantly, we are additionally producing an electronic ‘alert’ into our investigations software that, on requesting a repeat amylase, will prompt clinicians to consider its necessity.

Other centres offering acute treatment for similar patients may benefit from performing a similar audit to optimise care while reducing overall clinical costs.
P-P10 The survival benefit of pancreatic enzyme replacement therapy in adult patients undergoing treatment of pancreatic neuroendocrine tumours
Authors: Thompson Oscar , Hall Lewis , Roberts Keith , Shah Tahir , Bradley Elizabeth , Powell-Brett Sarah , Pande Rupaly
Published: December 2021

Background

Patients with pancreatic neuroendocrine tumours (pNETs), treated with somatostatin analogues (SSAs) or pancreaticoduodenectomy, are at risk of exocrine pancreatic insufficiency. This is frequently undiagnosed but can be treated with pancreatic enzyme replacement therapy (PERT). PERT improves survival and nutritional status in other exocrine pancreatic insufficiency-associated conditions such as pancreatic adenocarcinoma. This single-centre retrospective cohort study aimed to establish whether PERT increases survival or weight maintenance in SSA or pancreaticoduodenectomy-treated patients with pNETs.

Methods

Departmental databases identified patients (n = 82) diagnosed with pNETs between 2009 and 2019 and managed with SSAs and/or pancreaticoduodenectomy. Their baseline characteristics, treatments and outcomes were established from clinical records. Cases (n = 47) received PERT 3 months after either pancreaticoduodenectomy or commencement of SSAs, controls (n = 35) did not. Overall survival was analysed using the Kaplan-Meier method, the log-rank test and multivariable Cox regression. Percentage monthly weight changes were compared using the Mann-Witney U test. The cohort was investigated as a whole and stratified by intervention (pancreaticoduodenectomy or SSAs) as more cases having undergone pancreaticoduodenectomy was a potential confounder.

Results

Median survival was not reached in either group. Cases experienced significantly greater 5-year overall survival (81% vs 53%, p = 0.010), however, PERT was not independently associated with survival (Hazard ratio 0.47, 95% CI 0.17-1.30, p = 0.143). Cases showed superior median weight maintenance (+0.04% vs -0.10% per month, p = 0.013), but had lower mean baseline weights (70.0kg vs 81.9kg, p = 0.003). Considering SSA-treated patients (n = 55) only, cases (n = 27) showed greater median weight maintenance (+0.04% vs -0.21% per month, p = 0.025) and a trend towards improved median overall survival (55.5, 95% CI 10.3-100.7 vs 47.7, 95% CI 19.1-76.4 months, p = 0.054).

Conclusions

PERT may improve the maintenance of weight and therefore nutrition in patients with pNETs, treated with SSAs or pancreaticoduodenectomy. PERT may also convey a survival benefit in this same population, however, due to the numerous factors which affect survival, this study appears underpowered to reliably explore this outcome. Further studies are required to accurately define the use and benefits of PERT in this population.
P-P14 A multi-centre retrospective cohort study exploring weight loss and nutritional interventions in severe acute pancreatitis
Authors: Bourne David , Bibby Neil , Button Emily , Kenny Tara , Labaquere Marie , Lander Tom , Latimer Kate , Mahon Mary , Duggan Sinead , Griffin Oonagh
Published: December 2021

Background

Acute pancreatitis is among the most common acute gastrointestinal diseases. Severe acute pancreatitis (SAP) develops in up to 20% of patients and is associated with increased morbidity and mortality. Patients may have long and complex hospital admissions; nutritional support is a cornerstone of management. Due to increased metabolic demands and development of pancreatic exocrine insufficiency (PEI) patients frequently endure excessive weight loss. There has been little research into the effect of SAP on nutritional status and necessary nutritional interventions. This project aimed to characterise weight loss in SAP, routes of feeding, and PEI - including pancreatic enzyme replacement therapy (PERT).

Methods

Participating centres were recruited via the Nutrition Interest group of PSGBI and were required to retrospectively recruit 5-10 consecutive patients admitted following January 1st 2018 using a predefined data collection tool. Inclusion criteria included; age ≥18 years and diagnosed SAP of any aetiology (defined by organ failure of > 48hrs). The exclusion criterion was where death occurred during hospital admission. Data were collected regarding, weight changes, anthropometric measures, nutritional interventions used, PERT administration and diabetic status, including insulin use. All analyses were performed with IBM SPSS 22 (IBM Corp. Armonk, NY), with p < 0.05 considered statistically significant.

Results

34 patients (22 male) from five centres met the inclusion criteria and were included in data analysis. Most common aetiologies were gallstones (13/34) and alcohol (11/34). A mean weight reduction of 12.6% (SD ± 10.77) (p < 0.001) was observed. Multivariate analyses showed that higher premorbid weight (p = 0.02) and PERT administration with tube feeding (p = 0.005) were associated with weight loss. Most patients (29/34) received tube feeding; mean duration 56.8 (SD ± 58.29) days. There was a significant increase in patients with diabetes requiring insulin therapy from admission (n = 3) to discharge (n = 9) (p = 0.03). Most (29/31) patients required oral PERT prescription on discharge.

Conclusions

Patients with SAP lost significant weight during the course of their illness despite aggressive, extended nutritional support and the correction of PEI with PERT. The significant increase in insulin dependence among patients with diabetes, and the number of patients requiring PERT on discharge, reflects the destructive effect SAP has on pancreatic function. These multicentre findings could be used as a baseline for determining effectiveness of nutritional interventions in SAP and may provide a basis for further prospective research in this area.
P-P18 Thoracic epidural VS intrapleural analgesia for pancreaticoduodenectomy – a study on analgesic and non-analgesic outcomes
Authors: Yao Lu , Rajaretnam N , Smith N , Massey L , Rockett Mark , Aroori Somaiah
Published: December 2021

Background

Thoracic epidural analgesia (TEA) has been the traditional option for post-operative pain management for Kausch-Whipple pancreaticoduodenectomy (KWPD) via a ‘reverse L’ incision. An alternative option with inter-pleural analgesia (IPA) has become popular. However, the superior form of analgesia for KWPD regarding analgesic and non-analgesic outcomes is unclear. This study aims to establish if IPA is equivalent to TEA.

Methods

Retrospective study of all patients who underwent KWPD with ‘reverse L’ incision by a single surgeon between February 2014 to June 2016. All received either IPA or TEA post-operatively; patients who had rectus sheath catheter and spinal anaesthesia were excluded. To reduce bias, the Anaesthetist, rather than Surgeon, decided the choice of analgesia based on personal skill. Efficacy regarding analgesia were collected by nursing staff as patient-reported pain severity (mild, moderate or severe). Data were collected from patient case notes and electronic records. This study analysed analgesia efficacy, complications, inotrope use, and intensive treatment unit (ITU) stay.

Results

A total of 40 included in the study. Twenty-two patients had TEA (45% female, median age 68 years) and 18 had IPA (44% female, median age 67 years). Median Charleson Comorbidity Index (CCI) was 5 for both. Patient-reported pain was not statistically different (p = 0.15). We noted more analgesia complications with TEA (not working=4, leakage=2, haemodynamic instability=1, lower limb anaesthesia=1) than IPA (leakage=1; p = 0.027). Eleven (50%) TEA and eight (44%) IPA patients required inotropes. TEA patients required significantly longer duration (median duration 35 VS 18 hours, p = 0.047). Median ITU stay was 3 and 2 days for TEA and IPA patients, respectively.

Conclusions

Both TEA and IPA provide adequate pain relief for KWPD performed via a ‘reversed L’ incision. However, evidence suggests TEA was associated with significantly more analgesia-related complications and longer inotropic requirements. Furthermore, there was also a trend towards ITU stays with TEA. Therefore, we would recommend the use of inter-pleural analgesia over thoracic epidural.
P-P24 Optimising post-operative nutrition in patients undergoing pancreaticoduodenectomy
Authors: Gray Katie , Rana Mridul , Ceresa Carlo , Udupa Venkatesha , Soonawalla Zahir , Silva Michael , Friend Peter , Reddy Srikanth
Published: December 2021

Background

A considerable number of patients undergoing pancreaticoduodenectomy require supplemental nutrition in the postoperative period. However, there remains no national consensus on the optimal postoperative supplemental feeding modality. Furthermore, at our institution a variation in practice exists when considering post-operative entera (via the naso-jejunal (NJ)) or parenteral nutrition (PN). This study aimed to evaluate the utility of post-operative enteral or parenteral nutrition at our centre and to explore risk factors predisposing patients to post-operative nutritional deficits requiring supplementation. 

Methods

We retrospectively analysed the electronic case records of all patients undergoing a pancreaticoduodenectomy between November 2019 and November 2020 at our HPB specialist centre. Key patient demographic data and post-operative nutritional requirements with route, length and indication for supplemental feeding as well as biochemical markers, length of stay (LoS) and complications were collected and analysed. Data were analysed via intention to treat analysis.

Results

48 patients underwent a pancreaticoduodenectomy, of which 26 had an NJ tube inserted intra-operatively. 16 (33%) patients required supplemental feeding, via NJ route in 7 and PN in 9. 2 patients were intolerant to NJ feeds and progressed to PN. NJ fed patients had shorter LoS (12(10-42) vs. 28(14-63) days)(p = 0.09) compared to PN feeding. PN-related line infection or thrombosis in 4 (36%) patients. Supplemental feeding met daily kcal requirements in 13 (81%) patients, but PN was associated with greater weight loss (-5%) than NJ feeding (-3%). Significantly increasing the risk of needing supplemental nutrition: advanced age(p = 0.04), ASA≥2(p = 0.04) and anastomotic leak(p = 0.02).

Conclusions

In this group of patients, NJ feeding was largely well-tolerated and the majority of patients met their required daily kcal via this route. Due to the increased incidence of complications associated with PN, NJ feeding should be considered as the 1st line option for post-operative nutritional supplementation, with intra-operative insertion of an NJ tube considered for higher-risk patients.
P-P30 Outcomes from resection of pancreatic metastases and non-neuroendocrine, non-pancreatic tumours
Authors: Stevens Claire , Chin Sirr Ling , Karavios Dimitrios , Takhar Arjun , Arshad Ali , Hamady Zaed , Armstrong Thomas , Pearce Neil , Primrose John
Published: December 2021

Background

Isolated metastatic disease within the pancreas is an uncommon finding. The potentially higher perioperative risk and low incidence of resectable metastases has limited the development of evidence based guidelines for pancreatic metastectomy. However, reports in the literature suggest a considered approach to resecting patients with limited disease, favourable tumour type and a significant disease free interval. The aim of this study was to examine the indications and outcomes of pancreatic resection for metastatic disease and non-pancreatic, non-neuroendocrine malignancy at a high-volume pancreatic surgery centre.

Methods

This is a retrospective analysis of a prospectively managed database of pancreatic resections for metastatic disease or primary non-pancreatic, non-neuroendocrine tumours at a single institution. Data collected and analysed included patient demographics, operative details and peri-operative outcomes, subsequent survival and mode of recurrence.

Results

Records of 711 patients who underwent pancreatic resection were examined. 21 consecutive patients met the inclusion criteria, representing 3% of the unit’s throughput. The perioperative morbidity and mortality were 33% and 0% respectively. Overall survival was 86months (95%CI 63-107) for renal cell carcinoma and 64months for other tumours.

Conclusions

When coupled with the low morbidity and mortality rates of a high-volume pancreatic surgery centre using careful patient selection, pancreatic metastectomy has the potential to result in good long-term survival. Recent improvement in the efficacy of systemic therapies, particularly for renal cell carcinoma and melanoma contribute to the utility of resection and to the improved survival of patients.
P-P33 Quality of Life Assessment in Patients undergoing Robot Assisted Pancreaticoduodenectomy
Authors: Muhammad Qazi Rahim , Farrugia Alexia , Poole Hope , Ali Majid , Marangoni Gabriele , Ahmad Jawad
Published: December 2021

Background

Robot-assisted pancreaticoduodenectomy has recently gained attention as there is evidence from high volume centres suggests better outcomes and quick recovery. This study aimed to evaluate the quality of life after robotic-assisted pancreaticoduodenectomy

Methods

The study included the first 12 consecutive patients who underwent robotic pancreaticoduodenectomy. The RAND SF 36-Item health survey form was used to assess the quality of life through a one-hour face-to-face interview carried out by a junior doctor from a different team with no prior involvement in patient care. The interview was carried out at least three months postoperative period. Each item in the subscale was recorded with a pre-coded numeric value. The comparison was made between preoperative periods' scores defined by the onset of disease symptoms to surgery and the postoperative follow-up score. The SF-36 survey questions were supplemented with additional items such as postoperative pain, emotional wellbeing, and fatigue status.

Results

Analysis of SF-36 domains showed better quality of life postoperatively than the baseline, as evidenced by the mean physical functioning score from 82.91 to 90 and mean general health score from 37.9 to 69.5 postoperatively. 91.66% of the patients reported that they felt better at the time of study and were happy overall.

Conclusions

Robotic-assisted pancreaticoduodenectomy shows a better quality of life than in the preoperative period, which can be attained in a brief postoperative period.
P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre
Authors: Raza Syed Soulat , Nutu Anisa , Powell-Brett Sarah , Chatzizacharias Nikolaos , Dasari Bobby , Isaac John , Abradelo Manuel , Marudanayagam Ravi , Mirza Darius , Roberts Keith , Sutcliffe Robert
Published: December 2021

Background

Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix.

Methods

TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO.

Results

Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p < 0.001) were independently associated with TO.

Conclusions

Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.
P-P43 Lymph Node Negative Duodenal Adenocarcinoma Is Associated with Long-term Patient Survival following Pancreaticoduodenal Resection
Authors: Patel Pranav , Likos-Corbett Marina , Mudan Satvinder , Khan Amir , Kumar Sacheen , Bhogal Ricky
Published: December 2021

Background

Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy. Due to the low incidence of DA there is limited data reporting patient outcomes following radical pancreatic resection. Large retrospective single and multi-centre studies suggest that lymph node metastasis is an important factor for long-term patient survival following resection. The management of DA has tended to favour aggressive surgical resection with pancreaticoduodenectomy (PD), although a morbidity of up to 50% has been reported, mostly related to post-operative pancreatic fistulas. We assessed the disease-free (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy for DA in our institution.

Methods

We retrospectively analysed all patients undergoing pancreatic resection for DA at our institution between January 2009 – March 2020 inclusive. All DAs were cytologically or histologically proven prior to surgical resection following imaging review in a Hepato-pancreaticobiliary multidisciplinary team meeting. Patients underwent a Whipple’s with distal gastrectomy or pylorus preserving pancreaticoduodenectomy (PPPD) based on tumour size and location. Statistical analysis was performed by a Mann-Whitney U test using a p-value significance of 0.05 (SPSS, IBM, USA). DFS and OS curves were presented by Kaplan- Meier survival curves. 

Results

19 patients underwent pancreatic resection at our institution for DA during the study period. 12 patients underwent Whipple’s with distal gastrectomy and 9 patients underwent PPPD. The overall postoperative morbidity and mortality was 37% and 5% respectively. R0 resection was achieved in 18 patients (95%). 9 patients (47%) had no nodal involvement. Median follow up was 31 months (range 1-108 months). Median DFS was 17 months but was significantly higher in patients with no nodal metastasis [p < 0.001]. Median OS was 9.5 months for the whole cohort but was significantly higher in the patients with no nodal vs nodal metastasis (60 vs 17.5 months respectively) p < 0.003].  

Conclusions

DA can be resected by PD or segmental resection. PD is favoured due to improved resection margins and overall increased patient survival, despite an increased morbidity. Our series reports comparable morbidity and mortality to the published literature for DA resected by PD. This study reports a 95% R0 resection rate for DA with a 3- and 5-year survival of 50% and 30% respectively. DFS was found to be significantly higher in patients with no nodal disease, despite predominant T4 disease. This series has identified that lymph node metastasis is one of the most important prognostic determinants of long-term patient survival.

Program permission

yes
P-P52 Overuse of CT scans in the diagnosis of Acute Pancreatitis
Authors: Thomas Joel Joy , Mitra Smrthi , Vulliamy Paul , Osilli Dixon , Mukherjee Samrat
Published: December 2021

Background

Acute pancreatitis is an acute inflammatory process affecting the pancreas with variable involvement of local tissues and remote organs and may sometimes progress into necrosis of the pancreas. Diagnosis is usually made based on the clinical presentation of abdominal pain alongside a positive biochemical result of either serum amylase or lipase levels. Current guidelines by International Association of Pancreatology (IAP) state that early use of computed tomography (CT) is only indicated in patients who have no definite diagnosis, and should be delayed to at least 96 hours after the onset of the symptoms to evaluate complications. We aimed to assess the over-utilization of CT scans in the diagnosis of acute pancreatitis.

Methods

We performed a prospective cohort study of patients with confirmed acute pancreatitis who presented to a single NHS trust between March and April 2021. We included patients with at least two out of the three findings: (1) an acute abdominal pain, (2) elevated serum amylase levels of more than three times the normal range and (3) acute pancreatitis as evidenced on abdominal imaging. We defined inappropriate CT scans as those performed within 96 hours in the presence of both clinical and biochemical diagnostic criteria.

Results

A total of 53 patients met the inclusion criteria and were admitted with acute pancreatitis during this 2-month period at our trust. 54.7% (29/53) of this cohort had at least one CT scan performed during the index admission. 28.3% (15/53) of the admitted patients had an early CT scan performed in the presence of positive biochemical and clinical diagnostic criteria. This represents 51.7% of the total number of CT scans performed in the study group.

Conclusions

We found evidence of excessive use of CT scans in the early phase of acute pancreatitis for diagnostic purposes. Limiting the overuse of CT scans in the diagnosis of the same will not just reduce the financial burden of the hospital and trust, but also limit the avoidable exposure of patients to radiation.
P-P54 Interpreting trends in post-operative drain fluid amylase according to type of anastomosis used to form a pancreaticojejunostomy
Authors: Britton Emily , Ranat Reesha , Skipworth James , Pope Ian
Published: December 2021

Background

The formation of the pancreaticojejunostomy during pancreaticoduodenectomy is the most technically challenging aspect of the procedure, with its failure increasing rates of both morbidity and mortality significantly.  Early identification and management of a clinically relevant post-operative pancreatic fistula (CR-POPF) can be critical in reducing the threat of potentially avoidable harm to the patient.  The most used indicator for a CR-POPF is the level of drain fluid amylase.  There are many different techniques for forming the anastomosis, with considerable analysis but no consensus on superiority.   We aimed to look at our centres experience using different techniques and the trends we observed in drain amylases and clinical outcomes.

Methods

A prospective database of all patients in a single UK centre undergoing pancreatic or duodenal resection has been maintained.  This includes patient demographics, diagnosis pre and post operatively, operative details and duration, complications, and outcomes. All patients undergoing a pancreaticoduodenectomy between 1st January 2020 and 31st July 2021 were identified and their data retrospectively analysed.  

Results

Thirty-three patients underwent a pancreaticoduodenectomy during the study period.  The pancreatojejunostomy was formed using a duct-to-mucosa anastomosis in twenty-eight patients and using a dunking technique in five patients.

The mean of the highest drain fluid amylase on post-operative day one for the patients with a dunking anastomosis was 14804.8 (range 3643-43686), on day three 2376.12 (range 167-8008.6) and of the three patients whose drains were in situ at day 5 it was 522.2 (range 31 to 983. An 83.9% reduction in mean drain amylases was observed between Day One and Day Three, followed by a further 78% reduction between day 3 and day. One patient (20%) had a CR-POPF with a grade B fistula, two others had a biochemical leak. 

The mean Day One drain amylases for patients with a duct-to-mucosa anastomosis was 71% lower at 4274.5 (range 15.4 to 41755). However this increased by 11.5% by Day Three to 4766.4 (range 5 to 46300) before falling by 64.7% to 1681.9 (range 5 to 13015) on Day Five.  Eight patients (28.6%) had a CR-POPF – 3 grade B and 5 grade C fistula - and three patients had a biochemical leak.

Conclusions

In our centre’s experience, the type of anastomosis used to perform the pancreatic reconstruction post pancreaticoduodenostomy significantly impacts the post-operative trend in drain fluid amylase.  This is important for clinicians to appreciate in order to avoid premature suspicion of a CR-POPF and prevent potentially unnecessary intervention.
Effects of home-based Baduanjin combined with elastic band exercise in patients with chronic heart failure
Authors: Ma Chunhua , Zhou Wei , Jia Yanyan , Tang Qiubo
Published: December 2021

Aims 

Many studies show that aerobic exercise combined with resistance training is beneficial for patients with chronic heart failure (CHF). The benefits of traditional Chinese exercise Baduanjin combined with an elastic band in this population are not known. To evaluate the effects of Baduanjin in conjunction with an elastic band on exercise capacity, physical function, muscle strength of the upper and lower extremities, quality of life (QoL), and exercise self-efficacy among CHF patients in a home-based setting.

Methods and results 

A prospective randomized controlled trial was conducted in this study. A total of 136 CHF patients were randomly assigned to the exercise or the control group. Chronic heart failure patients in the exercise group received Baduanjin combined with elastic band and CHF community care, while those in the control group accepted CHF community care. The duration of the interventions was 24 weeks. The measured outcomes included exercise capacity, physical function, muscle strength of the upper and lower extremities, QoL, and exercise self-efficacy. A generalized estimating equation model was employed to examine the effects of Baduanjin combined with the elastic band on the outcome variables. Chronic heart failure patients showed significant improvements in physical performance testing (PPT) (P = 0.023), 30-s arm curl test (30ACT) (P = 0.035), 10 sit-stand-to-sit tests (STS10) (P = 0.017), 6-min walk test (6MWT) (P < 0.001), QoL (P < 0.001), and exercise self-efficacy (P = 0.009) in the exercise group, while these variables did not differ in the control group. There were also significant differences in these variables between the two groups at Weeks 12 and 24 (P < 0.05). There were significant group-by-time interactions in the exercise group, with enhancements in PPT (F = 5.40, P = 0.032), 6MWT (F = 9.04, P < 0.001), muscle strength in the 30ACT and STS10 (F = 5.32, P = 0.037; F = 6.69, P = 0.005), QoL (F = 6.69, P < 0.001), and self-efficacy (F = 4.60, P = 0.038) revealed in CHF patients in this group from baseline to Week 24.

Conclusion

Baduanjin combined with elastic band exercise may improve exercise capacity, physical function, muscle strength, QoL, and exercise self-efficacy for CHF patients in a home-based setting, which may be a complementary exercise model for home-based CHF patients who are clinically stable and cannot participate in centre-based exercise-based cardiac rehabilitation programmes.
Longitudinal Profiling in Phenotypic Metric of Aging: Insights From the Baltimore Longitudinal Study of Aging
Authors: Kuo Pei-Lun , Levine Morgan , Schrack Jennifer , Shardell Michelle , Ferrucci Luigi
Published: December 2021

It remains challenging to quantify the pace of aging across lifespan due to lack of comprehensive longitudinal measurements across wide range of age. In Baltimore Longitudinal Study of Aging, we have measured the longitudinal trajectories of more than 30 phenotypes across four pre-identified domain - body composition, energy regulation, homeostatic mechanisms and neurodegeneration/neuroplasticity, among participants with age between 20+ and 90+. We implemented a two-stage approach to summarize the longitudinal trajectories of these phenotypes across four domains into a summarized score. We demonstrated that higher summarized score (denoting for slower longitudinal phenotypic decline) is associated with slower decline in both cognitive and physical functions, across different stages of adulthood. Our results imply that deep longitudinal profiling contains rich information and may potentially replace diseases as an early endpoint in trials targeting at aging. Further, understanding the underpinning of longitudinal phenotypic trajectories may provide clues to the biological mechanisms of aging.