bluuebunny/crossref_metadata_2025 huggingface dataset:
P-BN45 The Impact of Covid-19 on Benign Upper GI Operations in England During 2020
Authors: Sandland-Taylor Laura , Jenkins Barbara , Beckingham Ian
Published: December 2021

Background

Since the cancellation of elective surgery in early 2020 due to the threat of Covid-19, surgical provisions in England have continued to be affected by the Covid-19 pandemic. Elective surgery makes up the majority of surgical procedures performed in England and therefore   cancelled operation lists and increased demand for ITU beds has had a significant impact upon the surgical services delivered to patients through out 2020. The following research looks at the impact of Covid-19 on benign upper GI surgery in England and reviews the relationship between Covid-19 deaths and operations performed throughout England and analyses the data at a regional level. 

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

The results show that there is a correlation with increasing Covid deaths and lower rates of elective surgery. Furthermore, elective surgery was worse hit than emergency surgery with a slower recovery overall. Cholecystectomies were reduced by a total of 20817 (31.4%) for the year 2020 with a greater reduction seen in elective operations (35.6%). However, similar reductions were seen in both laparoscopic (31.4%) and open (37.5%) Similarly, bile duct explorations and elective splenectomy were reduced by 34.4% and 23.4% respectively. Comparatively, both paraumbilical and inguinal hernias also saw reductions of greater than 40% in 2020 when compared to the mean of the previous 3 years. Regional variances were seen between operation numbers performed and Covid-19 rates, however the overall trend remained the same for national level data. 

Conclusions

Overall, the Covid-19 pandemic has had a significant impact on operations, particularly on those deemed as benign and ‘less urgent’. Whilst a global impact across all benign operations was seen, greater reductions were seen in elective operations compared to emergency operations. Hernia operations and bile duct exploration saw greater overall reductions compared to cholecystectomies and splenectomies, which suggests that whilst operation numbers were reduced, efforts were made to prioritise operations with greater clinical need throughout the pandemic. On analysis of the data in relation to Covid-19 rates and deaths, variation was seen across the regions in the UK, however overall the trend remained the same. Centres and regions worse hit by Covid-19 performed less operations during 2020. However, further qualitative research to investigate why certain centres maintained higher levels of performance during the pandemic would be beneficial for planning for future waves and future pandemics.
P-BN46 Risk Factors for Anastomotic Stricture after Hepaticojejunostomy for Bile Duct Injury – A Systematic Review and Meta-Analysis
Authors: Halle-Smith James , Hall Lewis , Mirza Darius , Roberts Keith
Published: December 2021

Background

After major bile duct injury (BDI), hepaticojejunostomy (HJ) is usually required. This can lead to good long-term patency but anastomotic stricture unfortunately remains common cause of long-term morbidity after major BDI. Although risk factors for adverse outcomes of BDI repair are reasonably well understood, there is a need to assimilate high level evidence to establish risk factors specifically for development of anastomotic stricture after HJ for BDI.

Methods

This was a systematic review of studies reporting rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Where possible, meta-analyses were then performed to establish risk factors for anastomotic stricture after HJ for BDI.

Results

The meta-analyses performed included five factors with a total of 2,155 patients from 17 studies. An increased rate of anastomotic stricture after HJ for BDI was shown amongst patients with concomitant vascular injury (OR 4.96; 95%CI 1.92-12.86; p = 0.001), post-repair bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p < 0.0001). Level of injury according to Strasberg Grade did not significantly affect the rate of anastomotic stricture (OR: 0.97; 95%CI 0.45-2.10; p = 0.93). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate.

Conclusions

Repair by a non-specialist surgeon was the only modifiable risk factor revealed by this meta-analysis and systematic review, which demonstrates the importance of broad awareness of these data. That said, knowledge of these risk factors permits evidence-based risk stratification of follow-up as well as better informed consent and understanding of prognosis for patients who have experienced major BDI and require HJ.
P-BN56 Anti-Reflux Surgery in the end-stage of the pandemic: Early results of the ARROW audit
Authors:   The ARROW collaboration
Published: December 2021

Background

Gastro-oesophageal reflux disease (GORD)  affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS).

We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of compliance with available guidelines.

Methods

International guidelines and consensus statements were collated and reviewed by the ARROW steering committee. Sources included NICE, ICARUS and BSG guidelines and AUGIS commissioning guidelines. Definitions were adopted from the Montreal consensus statements and the Chicago Classification of Esophageal Motility Disorders.  Audit fields were then iteratively developed by the steering committee and an online tool was developed to prospectively collect pseudo-anonymised patient data.

Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI trainees. The online tool was piloted in three centres. The protocol was published in Diseases of The Esophagus in January 2021.

Results

Of 240 registered patients on 25th August 2021, 171 had complete data. Median age was 57(range 19-83), 60.2% were females. 156 (91.2%) had OGD performed prior to surgery. 105 (61.4%) had manometry and 97 (56.7%) had 24-hour pH studies performed. 91 DeMeester scores were recorded, median score 38 (IQR 24-70). Median days from referral to surgery was 471, (range 1 to 1374). 167 patients (93.3%) underwent some variant of fundoplication. The most common wrap was a posterior 360° (44%) followed by a posterior 270°(27%) and anterior 180°(23%). 2 patients returned to theatre, 1 for recurrent hernia and 1 for ischaemia.

Conclusions

In keeping with all non-cancer elective work in the UK, ARS is recovering from the effects of the COVID pandemic, and this is reflected in long delays between referral and surgery. Compliance with established guidelines and consensus opinions has similarly been affected as access to diagnostic services has been impeded. Variation persists in the interventions offered to individuals and long-term outcomes monitoring to compare interventions is beyond the scope of this audit. Complication rates are very small with only 2 returns to theatre, 9 patients experiencing any short-term complication and only 24 delayed discharges.
P-EGS01 Cholecystectomy after gall stone pancreatitis
Authors: Ammar Ahmed , Elsayed Ahmed , Mohsin Mohammad , Shaaban Hossam
Published: December 2021

Background

According to the UK guidelines for the management of acute pancreatitis commissioned by the British Society of Gastroenterology,

All patients presenting with gallstone pancreatitis should be considered for cholecystectomy when they are well enough to undergo surgery. In cases of mild biliary pancreatitis, cholecystectomy should ideally be performed during the index admission or within 2 weeks of discharge as interval cholecystectomy is associated with a significant risk of readmission for recurrent biliary events.

In cases of severe gallstone pancreatitis, cholecystectomy may need to be delayed until collections have improved, unless the patient is well enough for surgery and the gallbladder is some distance from the collection

Methods

Methods

Inclusion Criteria

Exclusion Criteria

Results

80 patients were collected during the study period, 96 % of them were classified as mild pancreatitis

Cholecystectomy rate

Total percentage of cholecystectomies performed for mild gall stone pancreatitis during index admission or within 2 weeks from discharge : 37%

Percentage of early cholecystectomies for eligible patients (i.e.after ruling out unfit patients, patients declining treatment, previous cholecystectomy..etc) : 54%

Re-admission rate

Re-admission rate for early cholecystectomy patients : 7.4%

Re-admission rate for delayed cholecystectomy patients : 20.7%

Conclusions
P-EGS04 Assessment of Malnutrition in emergency laparotomy patients. A QIP highlighting simple measures can improve early recognition and optimisation of high-risk patients
Authors: Raslan Charef , Lasheen Omar , Tomalieh Feras , Siddique Khurram
Published: December 2021

Background

Early recognition of high-risk malnourished patients is important for optimisation of nutritional status leading to better outcomes.  The accurate recording of malnutrition universal screening tool (MUST) results is vital in this regard. This quality improvement project (QIP) aimed to review the quality of nutritional assessment of emergency laparotomy patients against the National Institute for Health and Care Excellence (NICE) guidelines and outline area of improvement.

Methods

The QIP was conducted at Royal Oldham Hospital in 2019-2020 over a seven-month period.  Fifty random patients were included in the first audit cycle over a 4-month period, followed by implementation of recommended changes and a re-audit of 30 patients over a 2-month period.  The initial MUST scores which were calculated and documented by nursing staff were identified as the nursing staff MUST score (NSMS). To assess the accuracy of NSMS, we developed a MUST rescoring method which was performed by a senior member of the medical team and was identified as the medical team MUST rescore (MTMR). 

Results

The initial audit showed a significant difference between NSMS and MTMR scores. According to MTMR, 23 patients (46%) had an inaccurate MUST score assessment by the nursing staff.  A multidisciplinary approach using a standard online calculator were recommended.  The second phase of the QIP showed an obvious improvement in the accuracy of MUST assessment. Our interventions improved the accuracy rate of MUST scores significantly (27, 54% vs 29, 96.6%, P = 0.00005).

Conclusions

A multidisciplinary team approach and online calculator are useful in improving the accuracy of MUST assessment in emergency laparotomy patients. This helped early involvement of the dietitian leading to improvement in morbidity and mortality.
P-EGS11 The Theatre Training Checklist: A Toolkit to Revive Post Pandemic Operative Training
Authors: Aldoori Joanna , Robson Andrew , Al-Attar Adam , Burke Josh , Giwa Lolade , O'Regan David , Peter Mark
Published: December 2021

Background

The COVID-19 pandemic has had a significant negative impact on operative surgical training, with trainee logbook numbers reduced by more than 50% compared to 2019. The operating theatre is expensive, costing approximately £1200 per hour to run. It is a crucial learning environment for many different trainees: anaesthetists, surgeons, operation department practitioners and surgical first assistants. For individuals to achieve their training requirements, the operating theatre as a training environment must be shared between all trainees. This requires excellent teamwork and leadership. The recovery phase of the COVID-19 pandemic is a unique opportunity to adopt novel training strategies. 

Methods

The Theatre Training Checklist is a simple framework that aims to facilitate awareness, understanding, coordination and cooperation of training for all members of the team (Figure 1). It is a practical strategy that can be adopted in any setting. Usually, trainers discuss informally with their trainees about their individual Skills, Experience, Expectationsand what is Achievable in a planned theatre list (SEEA). However, there currently is limited opportunity to discuss this between different disciplines and the wider team. This tool aims to refine communication, optimize training, manage expectations and ensure equity across the board. The checklist has been introduced and trialed locally. 

Results

The checklist is completed at the start of the list during the theatre brief. It identifies all trainees and their specific needs within the operating theatre session to the whole team. An agreed strategy is developed on how to achieve identified training goals (figure 2). Sometimes it may not be possible to allow a trainee to perform a particular procedure. However, other opportunities for training in theatre exist, such as: patient positioning, choice of equipment, types of techniques, discussions around consenting and complications etc. Feedback undertaken from the multiprofessional team after local trialing of the checklist has been positive. 

Conclusions

The Theatre Training Checklist aims to create dialogue and shared understanding of training needs among all parties within the operating theatre. The Theatre Training Checklist Toolkit is available for use and consists of the checklist tool and an instructional video. The Theatre Training checklist is being piloted in some centers and we hope to have the opportunity to present some early findings at AUGIS 2021.
P-L06 Establishing minimum datasets and disease specific forms for cancer patients in multidisciplinary team meetings
Authors: Agrawal Simrita , Ponniah Gobeka , Roberts Keith
Published: December 2021

Background

Multidisciplinary team (MDT) meetings aim to ensure standardised access to cancer pathways and treatment. It is thus important that minimum datasets are established and provided to the MDT clinicians to facilitate thorough discussion and encourage shared decision making. To determine the effectiveness of pre-established minimum dataset proformas for periampullary tumours, hepatocellular carcinoma (HCC), colorectal cancer with liver metastases (CRLM) and hilar cholangiocarcinoma in cancer MDT meetings.

Methods

Cancer specific minimum dataset forms were developed by consultants to be implemented in MDTs for the four types of hepatobiliary pancreatic cancers: HCC, periampullary cancer, hilar cholangiocarcinoma and CRLM. 189 MDT reports and 184 referral letters were analysed from three weekly MDT meetings to determine the outcomes reported against those outlined in the proformas. The proformas were then implemented by consultants leading the weekly MDT meetings for three consecutive weeks. 128 MDT reports and 126 referral letters were re-audited from these MDT meetings to determine if there was a change in the outcomes reported.

Results

In this quality improvement project, 21.25% (11/52) of outcomes in MDT and 19.23% (10/52) of outcomes in the referral letters had a statistically significant difference in the reporting of outcomes from Cycle 1 to Cycle 2 across all four cancers. Greater changes in reporting were observed for outcomes that may carry higher prognostic value, such as tumour size and vascular invasion. Despite the notable difference in reporting seen for datasets consisting of smaller cohorts, the change was not statistically significant due to the insufficient statistical power proving the need for trialling such proformas in a wider population.

Conclusions

The minimum dataset proformas were associated with a limited gain in compliance with data reporting. Further work, with particular focus on user acceptability and attitudes is required to improve use of minimum dataset proformas in MDT.
P-L12 Exploring Pathological Signatures for Predicting Recurrence of Early-stage Hepatocellular Carcinoma Based on Deep Learning
Authors: Shi Yinghong , Qu Weifeng , Tian Mengxin , Qiu Jingtao , Qian Kun , Wang Zhixun , Liu Weiren , Tang Zheng , Zou Hao , Hou Yingyong
Published: December 2021

Background

Early-stage hepatocellular carcinoma (HCC) is the ideal indication for liver resection. High recurrence rate limits the radical possibility. Current clinicopathological determinants are insufficient to reliably evaluate the recurrence risk after surgery. To address this global issue, we aimed to use deep learning to explore novel pathological signatures based on histological slides for predicting early-stage HCC recurrence and to evaluate the relationship between histological features and multi-omics information.

Methods

576 pathological images collected from 547 patients with BCLC stage 0-A HCC who underwent hepatectomy from 2006 to 2015 were randomly divided into the training cohort and validation cohort. The external validation cohort was composed of 147 TNM I patients from TCGA database. Weakly supervised convolutional neural networks were used to identify six classes of HCC tissues. Pathological signatures were extracted and two novel risk scores were constructed by LASSO Cox to predict recurrence. The forecast performance of the scores and patients' prognosis were evaluated. The relationship between histological score (HS) and immune infiltrating cells was estimated by clustering analysis.

Results

The classification accuracy of HCC tissue was 94.17%. The C-indexes of histological score in the training, validation and TCGA cohorts were 0.804, 0.739 and 0.708, respectively. Multivariate analysis showed that microvascular invasion (HR = 1.46, 95% CI: 1.09-1.95) and HS (HR = 4.05, 95% CI: 3.40-4.84) were independent risk factors for recurrence-free survival. Patients in HS high-risk group had elevated  alpha fetoprotein, worse tumor differentiation and higher proportion of microvascular invasion. HS was positively correlated with the expression of CD14 in adjacent normal liver tissue (P = 0.013), and negatively correlated with the expression of CD8 in tumor (P < 0.001).

Conclusions

This study established and validated two novel risk scores based on the histological slides using deep learning. HS performed well in recurrence prediction for early-stage HCC patients and indication of important clinicopathological features.
P-L13 Proposed sampling methodology for improved accuracy of hepatic burden assessment in neuroendocrine tumours
Authors: Thorne Thomas , Hughes Simon , Pande Rupaly , Ford Samuel
Published: December 2021

Background

Hepatic burden is a significant confounder in the assessment of impact of primary tumour resection in metastatic small bowel neuroendocrine tumours (SI-NET). For SI-NET metastatic hepatic burden >10% disease replacement or > 5 hepatic metastases are known prognostic markers, though nomograms and scores do not adequately account for this. Most trials do not adequately account for hepatic burden when assessing the survival difference between SI-NET primary tumour resection and no resection. We propose a sampling methodology to more accurately assess metastatic liver burden in SI-NET and correlate with delayed resection vs. upfront primary tumour resection at a specialist NET surgical unit.

Methods

Patients referred for metastatic SI-NET between January 2003 and February 2020 were identified from a prospective dataset. The earliest CT scan after diagnosis was used. The axial, coronal and sagittal slice position limits of the whole liver were recorded. These limits allowed equitable slice position of the liver, with 8 equally distributed axial, 4 equally distributed coronal and 4 equally distributed sagittal slices. Each slice was used to define the liver and metastatic area as assessed using liver CT windows. Liver burden was estimated as percentage total metastatic area summed from all 8 axial, 4 coronal and 4 sagittal slices.

Results

157 total patients were on the collated data base and 46 patients were identified with an appropriate CT. Liver burden was positively skewed. Liver burden was significantly higher for delayed resection vs. upfront resection in all planes of assessment (axial: 11.61% vs. 0.14%, p = 0.003; coronal: 13.46% vs. 0.33%, p = 0.006; sagittal: 10.46% vs. 0.16%, p = 0.008). All planar assessments correlated well with one another (all Kendall’s tau ≥0.851, all p < 0.001). Liver metastatic burden correlated with total liver volume (Kendall’s tau 0.549-0.573, all p < 0.001).

Conclusions

Hepatic burden differs between resection groups in a small sample at our centre, highlighting the unmeasured confounders favouring primary tumour resection via positive bias. Therefore, hepatic burden needs quantifying in prospective studies that assess primary tumour resection in SI-NET. This is to ensure comparable groups after randomisation. Our method provides an assessment of this metastatic SI-NET liver burden.
P-O11 Surgical Ambulatory Care: Reducing surgical admissions whilst maintaining patient satisfaction. Experiences over a four year period
Authors: Pscia Alicja , Eley Jonathan , Forsyth Kathryn , Lawrie Nicola , Hay Yvonne , Stevenson Lynn
Published: December 2021

Background

The tri-association document; The future of Emergency General Surgery (2015) has a number of key recommendations for the provision of emergency general surgical care. Key recommendations include for senior surgeons to triage referrals and to utilise a “hot clinic” model.

Prior to 2016 in the authors’ hospital, all General Practitioner/community referrals were formally admitted to General Surgery. A consultant led ambulatory clinic with dedicated Advanced Nurse Practitioner support was instituted in October 2016. It offers preliminary assessment, phlebotomy and priority access to routine imaging modalities. The clinic is located in a tertiary hospital serving a population of 500,000.

Methods

A retrospective audit of prospectively collected referral and outcome lists for the Surgical Ambulatory clinic was conducted for the time periods of October 2016 to June 2021.  The two primary outcomes were defined as admission to the General Surgical ward and discharge to the community/non-general surgical specialty.

Secondary outcomes for patient satisfaction were measured by randomly distributing over a six week period a patient satisfaction survey. The survey was designed in accordance with trust guidance, was anonymous and would cover multiple lead Consultant encounters as a cohort.

Results

In total, 9069 patients presented to the surgical ambulatory clinic over a period of 44 months. 2347 (26%) were admitted to the General Surgical ward whilst 6717 (74%) were discharged directly from the clinic.

71% of survey responders rated their experiences of the ambulatory clinic as “Excellent”, 19% “Very Good”, 0.5% “Good” and 0.5% “Poor.”

Conclusions

The introduction of an ambulatory care model has demonstrated a marked reduction in surgical admissions whilst remaining favourable to the patient populace. This has a direct impact on overall bed occupancy rates. 

In the age of COVID-19, efforts must me made to reduce the the number of potential inpatient interactions to protect those most at risk. A reduced admission and bed occupancy rate will contribute to the reduction of this risk.
P-OGC07 The Role of Carbohydrate Loading on Lactate and Glucose Levels in Upper GI Cancer Surgery
Authors: Turnbull Charlotte , Hallward George , Davies Andrew , Kelly Mark , Gossage James , Baker Cara
Published: December 2021

Background

Surgical stress is a significant factor in metabolic dysregulation in the perioperative setting. Its impact on insulin resistance is regarded as one of the most detrimental effects, contributing to post-operative complications and poor outcomes. Clinical markers of this include glucose and lactate levels, with hyperglycaemia and hyperlactataemia the predicted responses by the body. One way of minimising the impact of surgical stress is pre-operative carbohydrate loading, which in theory will provide more substrate for metabolism. Our aim was to investigate whether carbohydrate loading had any impact on lactate and glucose levels in patients undergoing upper gastrointestinal cancer resections.

Methods

A retrospective observational feasibility study was performed looking at 42 patients who had undergone either an oesophagectomy or gastrectomy. Patients were divided depending on whether they received pre-operative carbohydrate loading. Lactate and glucose levels both intra-operatively and post-operatively were collected. Mean difference was compared between the two groups at 4 hours intra-operatively, 2 hours post-operatively and 12 hours post-operatively using unpaired t tests, with significance at P < 0.05. Variance between the two groups was analysed. Secondary outcomes included analysis based on type of operation, anastomotic leaks, and post-operative intravenous fluid use in the first 24 hours.

Results

There was no statistically significant difference in lactate levels between the two test groups at any time point. Mean difference at intra-operative 4 hours 0.0408mmol/L (+/- 0.2537, P = 0.8731); post-operative 2 hours 0.2697mmol/L (+/- 0.3008, P = 0.3754); post-operative 12 hours 0.2327mmol/L (+/- 0.2368, P = 0.3318). Glucose levels at the same time points were not significantly different: intra-operative 4 hours 0.068mmol/L (+/- 0.5322, P = 0.5746); post-operative 2 hours -0.2649mmol/L (+/- 0.4679, P = 0.5746); post-operative 12 hours 0.3773mmol/L (+/- 0.3629, P = 0.305). Secondary outcomes did not show any statistically significant differences between analysed groups.

Conclusions

Pre-operative carbohydrate loading does not seem to influence lactate or glucose levels in these patients either intra-operatively or post-operatively. The lack of significant differences between the two cohorts may be due to underpowering of the sample size, as this is a small feasibility study. We assume that carbohydrate loading would reduce insulin resistance and therefore lactate and glucose levels. However, could it be that carbohydrate loading is not having as much of an effect on patient metabolism as we think? A larger prospective study is recommended to investigate its impact on clinical biochemistry and patient outcomes.
P-OGC10 Long-term survival is not affected by complications after oesophagectomy
Authors: Nevins Edward J , Chmelo Jakub , Brown Joshua , Prasad Pooja , Phillips Alexander W
Published: December 2021

Background

Outcomes following oesophagectomy for oesophageal cancer continue to improve, but complications are common and can result in significant morbidity. Post-operative complications are known to impact upon peri-operative and short-term survival but the effect on long-term survival remains unclear. The aim of this study is to investigate the effect of post-operative complications on long-term survival following oesophagectomy.

Methods

A contemporaneously maintained database from a single centre was reviewed. All patients who underwent oesophagectomy between January 2010 and January 2019 were included. Patients were separated into three groups, those who experienced no or very minor complications (Clavien-Dindo 0 or 1), minor complications (Clavien-Dindo 2), and major complications (Clavien-Dindo 3-4). Those who died during the index hospital admission were excluded to correct for short-term mortality effects. Overall survival was analysed using Kaplan-Meier and log rank testing.

Results

Seven hundred and twenty-three patients underwent oesophagectomy during this time. Seventeen (2.4%) died during their index hospital stay, and were excluded from the survival analysis. The 30- and 90- day mortality was 1.1% (8/723) and 2.4% (17/723) respectively. There were 43.2% (305/706), 30.2% (213/706) and 26.6% (188/706) in the Clavien-Dindo 0-1, Clavien-Dindo 2, and Clavien-Dindo 3-4 group respectively.

Median survival across the three groups was equivalent (50, 57 and 51 months). Across all three groups, overall long-term survival rates were equivalent at 1 (87.5%, 84.9%, 83.5%), 5 (44.2%, 48.9%, 44.7%) and 10 years (36.7%, 36.0%, 36.7%) (p = 0.730).

Conclusions

Long term survival is not affected by complications, irrespective of severity, following oesophagectomy.
P-OGC23 Significance of neoadjuvant downstaging in gastric adenocarcinoma
Authors: Prasad Pooja , Sivaharan Ashwin , Wahed Shajahan , Phillips Alexander
Published: December 2021

Background

Neoadjuvant chemotherapy is established in the treatment of gastric adenocarcinoma. Histopathological regression as a result of neoadjuvant treatment can potentially have important prognostic implications in gastric cancer. There is little data comparing the clinical outcomes of patients with gastric adenocarcinoma at the same pathological stage with and without neoadjuvant treatment. The aim of this study is to determine the impact of neoadjuvant chemotherapy upon the prognosis of patients being treated for gastric adenocarcinoma. 

Methods

Consecutive patients with gastric cancer treated in a single, tertiary high-volume centre between 2007 and 2017 were evaluated. All patients with gastric adenocarcinoma were treated with either a subtotal or total gastrectomy with D2 lymphadenectomy. A stage-by-stage comparison of the extent of pathological downstaging was conducted for patients who received neoadjuvant treatment (ypTNM) and those that did not (pTNM). The pTNM and ypTNM stages were defined as per the TNM 8th Edition. 

Results

Among 384 patients undergoing gastrectomy for gastric adenocarcinoma, 141 patients received neoadjuvant chemotherapy. Of them, 86 patients (58.1%) benefitted from a downstaging effect. Patients with downstaged disease had improved overall survival compared to patients who did not respond to neoadjuvant chemotherapy (NR vs 66 months, p < 0.001). Downstaging by > 3 stages was the strongest independant predictor of overall survival (hazard ratio: 0.17; 95% Confidence Interval (CI) 0.062-0.44). Overall survival was significantly better when a stage-by-stage comparison was performed between patients in the ypTNM and pTNM groups.

Conclusions

Pathological staging following neoadjuvant chemotherapy is a more accurate predictor of prognosis compared to pre-neoadjuvant chemotherapy clinical stage with downstaged patients benefitting from lower recurrence rates and improved overall survival. Patients downstaged due to neoadjuvant chemotherapy receipt can potentially have more favourable clinical outcomes compared to stage-matched patients who did not receive this.
P-OGC27 Chyle Leak following Oesophagectomy: ‘A Retrospective 10-year Single-Site Experience of a Tertiary Centre.’
Authors: Koroma Paul , Chaudhury Madhu , Greenlees Alana , Ball Christopher , Shetty Vinutha , Turner Paul , Ward Jeremy , Pursnani Kishore
Published: December 2021

Background

Chyle leak is a relatively uncommon but well-recognised complication following Oesophagectomy which carries significant morbidity and mortality if not treated actively. Evidence suggests the incidence rate of chyle leak post oesophagectomy can range from 0.4% to 21%. The aim of this study was to describe our experience in managing this complication.

Methods

This was a retrospective study, using the electronic database, to analyse our incidence of chyle leak in all patients who underwent elective oesophagectomy from April 2009 to December 2019 in a Tertiary Upper GI cancer centre. The diagnosis was confirmed by high persistent chest drain output, the colour of the fluid produced in the chest drain and its ‘content’ including fluid triglyceride levels and the presence of chylomicrons.

Results

Between 2009-2019, a total of 550 patients underwent Oesophagectomy. The median length of stay was 13 (Range 3 to 148) days. The median age was 63 years (45 to 82) with M:F 2:1. Chyle leak was identified in 24 patients (4.4%); Patients who were managed surgically were 83.3%(n = 20) with a median LOS of 20 days (Range 11 to 148) and mortality of 5%(n = 1). 16.7%(n = 4) were managed conservatively with a median LOS of 31 days (Range 14 to 51) and mortality of 0%.  All 24 patients with chyle leak had neoadjuvant chemotherapy as part of treatment with radical intent. 

Conclusions

Low mortality rates with chyle leak can be achieved with a high index of suspicion and early surgical intervention. This is crucial in reducing the length of stay in hospital and morbidity. Conservative management is suitable in low volume chyle leak and cases clinically responding to medical management.
P-OGC33 Incidence, diagnosis and management of malabsorption following oesophagectomy: a systematic review
Authors: Khaw Rachel A , Nevins Edward J , Phillips Alexander W
Published: December 2021

Background

Survival following oesophagectomy for oesophageal cancer is increasing. This has resulted in increased focus on quality-of-life and improved survivorship. Weight loss and malnutrition occurs in 25-46% of patients after three years, with associated adverse gastrointestinal symptoms. Malabsorption syndrome is multifactorial and includes exocrine pancreatic insufficiency (EPI), small intestinal bacterial overgrowth (SIBO) and bile acid malabsorption (BAM), however there is little literature available in patients following oesophagectomy. The aim of this study was to evaluate the reported incidence and management of malabsorption syndromes post-oesophagectomy.

Methods

A systematic search of PubMed, EMBASE, MEDLINE, Scopus and the Cochrane Library evaluating incidence, diagnosis and management of malabsorption was performed for studies published until March 2021.

Results

Of 461 identified studies, seven studies (6/7 non-randomised observational studies) were included, with a combined population of 344 (range 7-87). Incidence of malabsorption syndromes including EPI, SIBO and BAM were 10.2-100%, 37.8-100% and 3.33-100% respectively. There was no consensus definition for EPI, SIBO or BAM; and there was variation in diagnostic methods. Diagnostic criteria varied from clinical (gastrointestinal symptoms or weight loss), or biochemical (faecal elastase, hydrogen breath test and Selenium-75-labelled synthetic bile acid measurements). Treatment modalities using pancreatic enzyme replacement, rifaximin and colesevelam showed improvement in symptoms and weight in all studies.

Conclusions

Malabsorption syndromes following oesophagectomy are likely to be severely underestimated. The resultant gastrointestinal symptoms have a negative effect on post-operative quality of life. Current literature suggests benefit with outlined therapies, however greater understanding of these conditions, their diagnosis, and management is required to further understand which patients will benefit from treatment.
P-OGC37 Lymphatic embolisation for chylous abdomen following oesophagectomy
Authors: Ghauri Sherafghan , Abdelrahman Mohamed , Miles Richard , Chan David
Published: December 2021

Background

A 78 year old man underwent an Ivor Lewis oesophagectomy (laparoscopic converted to open abdominal phase, right thoracotomy) for a T2 N2 (3/81) R0 Type II GOJ adenocarcinoma post FLOT neoadjuvant chemotherapy. He developed a chylous abdomen requiring drainage radiologically. A percutaneous lymphatic embolisation was performed which showed a leak in the region of the cisterna chyli which was successfully treated.

Methods

A lymph node in each groin was cannulated under US guidance using spinal needles and an infusion of Lipiodol was started at a rate of 6ml/hr each side. Lymphatic opacification was monitored under fluoroscopy with contrast having reached the cisterna chyli within 30 minutes. Contrast was seen extravasating near cisterna chyli, confirming an injury at this site. A lumbar trunk lymphatic was cannulated with a Chiba needle and wire enabling positioning of a microcatheter as close to the point of injury as possible. Onyx liquid embolic was used to embolise the feeding lymphatic trunk.

Results

Post-procedural drain outputs demonstrated an immediate significant drop, with losses of only 300ml/24hr within 48 hours. Drain outputs continued to taper and the drains removed shortly after. The cisterna chyli is typically thought of as a retroperitoneal/para-aortic structure not prone to instrumentation during an ILGO. Despite reviewing the intra-operative footage, a definitive moment/point of injury remains unclear.

Conclusions

Conservative management of abdominal chyle leak including use of TPN and octreotide  is often effective but in sustained large volume ascites(>1000mls/24hr) this is unlikely to succeed. Percutaneous lymphatic embolization can be offered as a treatment option for these patients.
P-OGC40 Enhanced recovery after oesophagectomy at Oxford University Hospitals: the benefit of having a discharge target
Authors: Menon Nainaka , Antonowicz Stefan , Matarangelo Antonio , Ash Stephen , Owen Richard , Ferraro Daniele , Ghafoor Hamira , Gillies Richard , Marshall Robert , Sgromo Bruno , Maynard Nick
Published: December 2021

Background

Enhanced recovery after surgery (ERAS) is a multimodal approach to decreasing morbidity and accelerating return-of-function after major surgery. However, the majority of patients undergoing oesophagectomy for cancer experience some kind of complication, which extends their admission and causes pathway deviation. Thus, the value of having a discharge target (Day 8 at our institution) could be challenged. In this study we reviewed our experience using this pathway, with a focus on: (i) whether length of stay and morbidity has improved since pathway implementation (ii) describing the medical and non-medical reasons for extended admission (iii) identifying pre-operative predictors of pathway deviation.

Methods

A retrospective review of a prospectively maintained database was performed. Complications are recorded during routine clinical care using standardised definitions set out by the Esophageal Complications Consensus group,  and are updated in the database at a weekly departmental meeting. Median and interquartile range were used for descriptors and differences tested with Mann-Whitney U test or Chi squared tests, using SPSS ver 26. Multivariable models were fitted to establish independent predictors of pathway deviation, using a binary logistic regression approach with bootstrapping.

Results

150 of 448 patients met the 8-day target. Patients treated since 2018 were significantly more likely meet their discharge date (OR 1.28, P = 0.041) compared to 2015-2017, and have less complications. Surgical quality was unchanged. Thirty-day mortality increased but was still low (0.9% vs 1.8%, P = 0.067).  Aside from having a complication (OR 4.15,  P < 0.001), independent predictor of delayed discharge was female sex (OR 2.6, P = 0.003), squamous cell cancer histology (OR 2.8, P = 0.014) and low socio-economic status (OR 1.33, P = 0.014), but not age, smoking, BMI, co-morbidities and other baseline variables.

Conclusions

Enhanced recovery after oesophagectomy provides clear goals for the patient and multi-disciplinary team, however the target is often not met owing to the frequent nature of post-operative complications. Nonetheless these targets provide a culture for accelerated recovery, with steady improvement in short-term outcomes over time.  A number of specific patient-groups are more likely to have extended admissions independent of complications, which has implications for optimising prehabilitation services. Overall , these findings suggest that having a discharge target is valuable,  even though it often is not met.
P-OGC57 Predicting survival and response to therapy using diagnostic biopsies: A machine learning approach to facilitate treatment decisions for oesophageal adenocarcinoma
Authors: Rahman Saqib , Early Joseph , Sharpe Ben , Lloyd Megan , Vries Matt De , Grace Ben , Ramchurn Sarvapali , Underwood Timothy
Published: December 2021

Background

Standard of care for locally advanced oesophageal adenocarcinoma is neoadjuvant chemotherapy or chemoradiotherapy followed by surgery. Only a minority of patients (<25%) derive significant survival benefit from neoadjuvant treatment and there are no reliable means of establishing prior to treatment in whom this benefit will occur. Moreover, accurate prediction of survival prior to treatment is also not possible. The availability of machine learning techniques provides the potential to use complex data sources to answer these problems. In this study, we assessed the utility of high-resolution digital microscopy of pre-treatment biopsies in predicting both response to neoadjuvant therapy and overall survival.

Methods

A total of 157 cases were included in the study. Pre-treatment clinical information, including neoadjuvant treatment, was obtained, along with diagnostic biopsies. Diagnostic biopsies were converted into high-resolution whole slide-images and features extracted using the pre-trained convolutional neural network Xception. Single representative images were converted into patches from which predictive models were trained. Elastic net regression classifiers were derived and validated with bootstrapping and 1000 resampled datasets. The response to treatment was considered according to Mandard tumour regression grade (TRG). Model performance was quantified using the C-index (for TRG) and time-dependent AUC (tAUC, fo Overall survival) along with calibration plots.

Results

Median survival was 78.9months (95%CI 35.9 months – not reached). Survival at 5-years was 52.1%. Neoadjuvant treatment was received by 123 patients (78.3%), with a significant response seen in 45 cases (36.6%). A response was more likely in those patients who received chemoradiotherapy than chemotherapy (53.3% vs 23.1% p < 0.001) and in older patients (median age 69.4 vs 66.0 years, p = 0.038), with other characteristics similar. A predictive model for response to neoadjuvant treatment derived from image features and clinical data achieved good discrimination (C-index 0.767, 95%CI 0.701-0.833) and calibration. Accuracy of prediction of overall survival was more modest (tAUC 0.640, 95%CI 0.518-0.762).

Conclusions

Using a small dataset, utility of a feature extraction pipeline in prediction of patient level outcomes has been demonstrated. This was more marked in prediction of response to neoadjuvant treatment than overall survival, which may reflect the importance of pre-treatment clinical data in determining the former outcome. Further study to refine the methodology and confirmation in larger datasets are required before expansion to clinical settings.
P-OGC66 Mental Health and Wellbeing Services for Patients with Upper GI Cancer
Authors: Coleman Claire , Hickey Wendy , White Cathy
Published: December 2021

Background

Cancer related distress has a major impact on quality of life. The psychosocial needs of patients post an oesophagectomy  are significant and exacerbate the physical burden. The Upper GI MDT at our hospital aim to provide holistic patient centred care that equips patients mentally and physically for their treatment pathway. Formal or structured pyschoncology services are not routinely available to our patient cohort. The aim of the audit undertaken was to assess awareness of and subsequent engagement with available mental health services in patients undergoing a curative resection for oesophagogastric cancer.

Methods

Patients who underwent either a gastrectomy or oesophagectomy in the Upper GI Centre between Nov 2018 and May 2019 were included. They each received a questionnaire to complete anonymously. Responses were via prepaid post. Responses were collated and analysed.

Results

36 questionnaires sent out with 21 patients responding (Response rate 58%).

Average age:69 (age range 40-84).

18 of the 21 responses were male

Time diagnosed with cancer: 57% were between 12 to 18 months post diagnosis and 43% between 6 to 11 months.

Source of Information received: 43% reported verbal information provided and 38% reported written information was provided

Current engagement with Mental Health Services: National, Community, and Exercise programmes were used by a very small number of  patients - 6 in total out of 21 respondents 

Reasons for not engaging with Mental Health Services responses included ‘Not being interested or required' to ‘fearful' ‘No knowledge of service' to ‘Cant remember ' or ‘Plans to engage'

93% of respondents would recommend use of wellbeing or mental health services to someone with a diagnosis of an Upper GI Cancer

Suggestions for improvements varied from use of information packs, information on life post op and more guidance needed surrounding availability of current mental health supports 

Conclusions

Psychosocial issues need to be addressed and there is a huge deficit in current service provision. Current service is not meeting service user needs and not empowering patients how best to manage mental burden and thus contribute to maximising treatment outcomes. National Cancer Strategy acknowledges lack of access for cancer patients to pyschoncology services. The Cancer Centre is awaiting appointment of a Pyschoncology Consultant and Team in the coming months. The Upper GI MDT will seek access to this service once available for their patient cohort. In interim use limited national and community resources available. Provide education to wider team members to standardise approach providing both written and verbal information on available mental health and well being services, embed mental health awareness into daily practice with encouragement for early patient intervention if cancer related distress evident. Re Audit after introduction of these measures.
P-OGC70 Chyle leak management and long-term survival post esophagectomy for oesophageal cancer
Authors: Askari Alan , Wong Joshua , Riaz Amjid
Published: December 2021

Background

Chyle leak can be a serious complication following oesophagal cancer resection. The aim of this study is to determine the rate of chyle leak, its management and impact on short-term surgical outcomes and overall long-term survival.

Methods

Analysis of a prospectively maintained database of patients undergoing esophagectomy for oesophagal cancer between January 2011 and April 2019 were undertaken. Short term and survival comparisons were made between the chyle leak and non-chyle leak groups.

Results

A total of 190 patients underwent esophagectomy at our hospital over this time period, of whom 3.7% (n = 7/190) had a chyle leak. The length of stay was longer in the chyle leak group  (27 days, IQR 13-55 vs 12 days, IQR 11-14 days,  P=0.001), they had a higher rate of return to theatre (42.9% vs 8.8%, P = 0.003) and higher rate of overall mortality (57.1% vs 35.0%, p = 0.039) compared to the non-leak group. They also experienced worse survival ( 9.0 months, 95% CI 5.5-12.4 vs 66 months, 95% CI 59.6-73.6, P = 0.001).  

Conclusions

Chyle leak can occur in approximately 1 in 25 patients and is associated with prolonged intensive therapy unit stay, higher risk of return to theatre as well as a lower overall cancer survival.