bluuebunny/crossref_metadata_2025_split huggingface dataset:
P-P22 NET Profit: Considering quality of life assessment in patients treated with SSAs for NETs
Authors: Hall Lewis , Powell-Brett Sarah , Thompson Oscar , Bradley Elizabeth , Smith Stacey , Vickrage Suzanne , Kemp-Blake Joanne , Shah Tahir , Roberts Keith 
Published: December 2021

Abstract

Background
Somatostatin Analogue (SSA) therapy of neuroendocrine tumours (NETs) leads to pancreatic exocrine insufficiency (PEI). PEI symptoms include diarrhoea, abdominal discomfort, bloating, and steatorrhea, which negatively impact quality of life (QoL). NETs (and the sequelae of carcinoid syndrome) however, have similar symptomatology to PEI, with a comparably negative impact on QoL. QoL tools exist to assess PEI and its response to enzyme therapy; however, we hypothesise that PEI symptom scale scores will be unreliable in SSA-induced PEI due to the concurrent improvement of the carcinoid symptoms.

Methods
Adult patients commencing SSA therapy for NETs were recruited from December 2020. Qualitative assessments of the impact of SSAs and pancreatic exocrine function on patient QoL were performed before and during (at 8 weeks) therapy. The Pancreatic Exocrine Insufficiency Questionnaire (PEI-Q) was used to capture patient-reported assessment of relevant symptoms. Health-related QoL was assessed using the European Organisation Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLC)-C30, supplemented by the EORTC GI.NET.21. Patients were specifically asked about steatorrhea at both assessments.

Results
Seven patients completed the study. 5-HIAA levels were raised in 4/7 patients, indicative of carcinoid syndrome, secondary to the NET. Pancreatic exocrine function reduced after SSA therapy in all patients (data reported elsewhere) but paradoxically PEI-Q symptom scale scores reduced (median decrease from baseline: -18.5%, range: -1.5- -55.6%; p = 0.018) (Figure 1). According to PEI-Q, all seven patients would meet the criteria for a mild PEI at baseline, and two would be considered severe. One patient reported steatorrhea after commencing SSA-therapy. No changes in relevant domains of EORTC questionnaires were statistically significant, including functional, symptomatic, and overall health scores.

Conclusions
The PEI-Q tool is not useful for assessing SSA-related PEI due to substantial symptom overlap with the tumour itself and SSA therapy. The decrease in symptom score is likely due to improvement of carcinoid syndrome, independent of PEI. Although the cardinal PEI symptom is steatorrhea, there is no distinction between that and diarrhoea in the EORTC tool, and confounding aetiologies of diarrhoea in NET patients may further complicate assessment. Current available QoL measures are of limited use in the setting of SSA-related PEI, and care should be taken if evaluating PEI or response of PEI to treatment.
P-P23 Adjuvant chemotherapy in the treatment of intraductal papillary mucinous neoplasms of the pancreas: systematic review and meta-analysis
Authors: Chong Eric Jing Fu , Ratnayake Bathiya , Dasari Bobby V M , Loveday Benjamin PT , Siriwardena Ajith K , Pandanaboyana Sanjay 
Published: December 2021

Abstract

Background
The present systematic review aimed to compare survival outcomes of invasive intraductal papillary mucinous neoplasms (IIPMNs) treated with adjuvant chemotherapy versus surgery alone and to identify pathologic features that may predict survival benefit from adjuvant chemotherapy.

Methods
A systematic search of Medline, Pubmed, Scopus, and EMBASE was performed using the PRISMA framework. Studies comparing adjuvant chemotherapy and surgery alone for patients with IIPMNs were included. Primary endpoint was overall survival (OS). A narrative synthesis was performed to identify pathologic features that predicted survival benefits from adjuvant chemotherapy.

Results
Eleven studies and 3393 patients with IIPMNs were included in the meta-analysis. Adjuvant chemotherapy significantly reduced risk of death in the overall cohort (HR 0.57, 95%-CI:0.38-0.87, p = 0.009) and node-positive patients (HR 0.29, 95%-CI:0.13-0.64, p = 0.002). Weighted median survival difference between adjuvant chemotherapy and surgery alone in node-positive patients was 11.6 months (95%-CI:3.83-19.38, p = 0.003) favouring chemotherapy. Adjuvant chemotherapy had no impact on OS in node-negative patients (HR 0.53, 95%-CI:0.20-1.43, p = 0.209). High heterogeneity (I2&gt;75%) was observed in pooled estimates of hazard ratios. Improved OS following adjuvant chemotherapy were reported for patients with stage III/IV disease, tumour size &gt;2 cm, node-positive status, grade 3 tumour differentiation, positive margin status, tubular carcinoma subtype, and presence of perineural or lymphovascular invasion.

Conclusions
Adjuvant chemotherapy was associated with improved OS in node-positive IIPMNs. However, the findings were limited by marked heterogeneity. Future large multicentre prospective studies are needed to confirm these findings and explore additional predictors of improved OS to guide patient selection for adjuvant chemotherapy.
P-P36 AXIOS™ stents in the management of pancreatic fluid collections: case series from a single healthcare trust
Authors: Doyle Joseph , Latip Nadiah , McCain Stephen , Scott Ryan , Love Mark , Taylor Mark , Vass David , Jones Claire , Kirk Gareth , McKie Lloyd , Diamond Thomas 
Published: December 2021

Abstract

Background
This was a consecutive case-series of all pancreatic fluid collections (PFCs) managed with AXIOS™ stents in a 3 year period from a single healthcare trust, retrospectively analysed to determine the rate of technical success, clinical success and adverse events related to the procedure.

Methods
All patients in who underwent AXIOS stenting for PFCs in the Belfast Health and Social Care Trust between May 2016 and July 2019 were included, with a follow-up period of 1 year. Electronic care records (ECR) and Radiology reports were reviewed for each patient. PFCs were categorised into walled-of pancreatic necrosis (WOPN) and pseudocysts as per the revised Atlanta classification. The number of repeat procedures, endoscopic lavage +/- necrosectomy, the need for definitive surgery or any adverse events post-procedure were recorded.

Results
45 patients were included in the study (21 male, 24 female). 17 patients (37.8 %) had WOPN and 28 (62.2 %) pancreatic pseudocysts. Median collection diameter on CT imaging was 12 cm (range 6.2 – 22 cm).
The procedure was technically successful in 43 patients (95.6%), with stent mal-deployment in the remaining 2. Median duration for stenting was 29.5 days (Range 13 – 92).
The procedure was clinically successful for 33 patients (73.3%). n = 8 (17.8%) of patients were re-admitted with sepsis following stent insertion requiring intravenous antibiotics. n = 16 (35.6%) patients required repeated endoscopic lavage +/- necrosectomy following stent blockage (n = 11 WOPN, n = 5 pseudocyst). n = 2 (4.4%) stents accidentally dislodged during lavage necessitating surgical removal. n = 4 (8.9%) patients required a second AXIOS stent within 45 days of removal, n = 2 (4.4%) required CT guided drainage and n = 8 (17.8%) ultimately required surgical intervention.The rate of adverse events post-procedure was 33.3%.

Conclusions
AXIOS stenting appears to be effective first-line in the “step-up” approach to managing PFCs. Despite some drawbacks, our study showed they were technically successful in 95.6% and clinically successful in 73.3% of cases, requiring no further intervention. For PFCs that do require surgery, AXIOS stenting may allow for a period of patient optimisation prior to definitive treatment.
P-P38 External validation of post-operative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis
Authors: Pande Rupaly , Halle-Smith James , Phelan Liam , Thorne Tom , Hodson James , Roberts Keith J ,   PARANOIA Study Group
Published: December 2021

Abstract

Background
Multiple risk scores claim to predict the probability of post-operative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation which score is the most accurate.
Objective: To identify risk scores and assess the clinical validity of these scores.

Methods
Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models.

Results
Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so were included in the meta-analysis, namely the Tokyo (N = 2 validation studies), Birmingham (N = 5), FRS (N = 19), a-FRS (N = 12), m-FRS (N = 3) and ua-FRS (N = 3) scores. The overall predictive accuracies were found to be similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%.

Conclusions
Most risk scores lack external validation, their predictive accuracies were limited and similar across risk scores. Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.
P-P39 Perioperative Interventions to Reduce Pancreatic Fistula following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis
Authors: Halle-Smith James , Pande Rupaly , Hall Lewis , Hodson James , Roberts Keith J ,   PARANOIA Study Group
Published: December 2021

Abstract

Background
Many studies evaluate interventions to reduce POPF following PD, but often report conflicting results. Previous meta-analyses have generally included non-randomised trials and not considered novel interventions.

Aim
To evaluate interventions to reduce postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) with level 1 data.

Methods
A systematic review and meta-analysis assessed randomised controlled trials (RCTs) evaluating interventions to reduce All-POPF or clinically relevant (CR)-POPF after PD. A post-hoc analysis of negative RCTs assessed whether these had appropriate levels of statistical power.

Results
Among 22 interventions (n = 7,512 patients, 55 studies), 12 were assessed by multiple studies, and subject to meta-analysis. Of these, external pancreatic duct drainage was the only intervention found to be associated with significantly reduced rates of CR- and all-POPF. In addition, Ulinastatin was associated with significantly reduced rates of CR-POPF, whilst invagination (vs duct to mucosa) pancreatojejunostomy was associated with significantly reduced rates of all-POPF. Review of negative RCTs found the majority to be underpowered, with post-hoc power calculations indicating that interventions would need to reduce the POPF rate to ≤ 1% in order to achieve 80% power in 16/34 (All-POPF) and 19/25 (CR-POPF) studies, respectively.

Conclusions
Meta-analysis supports a role for several interventions to reduce POPF after PD, although data is often inconsistent and/or based on small trials. Systematic review identifies other interventions which may benefit from further study. However, underpowered trials appear to be a fundamental problem, inherently more so with CR-POPF. Larger trials, or new directions for research are required to further understanding in this field.
P-P40 Can trainees safely perform pancreatoduodenectomy? A systematic review, meta-analysis and risk-adjusted analysis of post-operative pancreatic fistula
Authors: Pande Rupaly , Halle-Smith James , Thorne Tom , Hodson James , Roberts Keith J ,   PARANOIA Study Group
Published: December 2021

Abstract

Background
The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining operative experience.

Objective
to compare the POPF rate following PD by trainees or established surgeons.

Methods
A systematic review of the literature was performed using PRISMA guidelines, with differences in POPF rates after PD between trainee-led vs. consultant/attending surgeons pooled using meta-analysis. Variation in rates of POPF was further explored using risk-adjusted outcomes using published risk scores and CUSUM analysis in a retrospective cohort.

Results
Across 14 cohorts included in the meta-analysis, trainees tended towards a lower, but non significant rate of All-POPF (odds ratio [OR]: 0.77, p = 0.45) and clinically relevant (CR)-POPF (OR: 0.69, p = 0.37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width &lt;3mm (OR: 0.45, p = 0.05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted All-POPF (median: 20 vs. 26%, p &lt; 0.001) and CR-POPF (7 vs. 9%, p = 0.020) rates than consultant/attending surgeons, based on pre-operative risk scores. After adjusting for this on multivariable analysis, the risks of All-POPF (OR: 1.18, p = 0.604) and CR-POPF (OR: 0.85, p = 0.693) remained similar after PD by trainee or consultant/attending surgeons.

Conclusions
PD, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.
P-P41 Systematic review of Sarcopenia in Chronic Pancreatitis: prevalence, impact on surgical outcomes and survival
Authors: Bundred James , Thhakar Rohan G , Pandanaboyana Sanjay 
Published: December 2021

Abstract

Background
Chronic pancreatitis(CP) is characterised by progressive inflammatory changes to the pancreas, leading to loss of endocrine and exocrine function. Emerging literature suggests sarcopenia may adversely affect outcomes for chronic pancreatitis patients. This systematic review examines the evidence surrounding the impact of sarcopenia on patients with CP.

Methods
A systematic literature search of PUBMED, MEDLINE and EMBASE databases identified articles describing body composition assessment in patients with CP. Data collected included definitions of sarcopenia, assessment methodology, baseline demographics, surgery related data and short- and long-term outcomes.

Results
9 studies, including 977 patients and a sarcopenia prevalence of 32.3% were included. Alcohol was the predominant aetiology. There was significant heterogeneity in definitions of sarcopenia used. CT was the main modality to assess for sarcopenia in 7 papers, MRI in 2 papers and clinical measurements in 2 papers. 2 papers included patients undergoing total pancreatectomy and Islet cell transplantation. None of the studies found a significant increase in complications with sarcopenia. 1 Year mortality in outpatients from one study of patients with CP was 16% in sarcopenic patients versus 3% (HR:6.69(95%CI:1.79–24.9),p&lt;0.001).

Conclusions
Sarcopenia is prevalent in patients with CP and has adverse impact on short- and long-term survival.
P-P45 Prognostic Value of CRP in Post-PPPD and Whipple’s Re-Intervention
Authors: Macias Ana Maria Saenz , Frampton Adam 
Published: December 2021

Abstract

Background
Several studies have aimed to use different biochemical and haematological markers to predict relevant post-operatively pancreatic fistulas after hepatobiliary operations, however none has been defined as the gold-standard. This study aimed to evaluate the sensitivity and specificity of day 3 C-reactive protein (CRP) and drain amylase values in predicting re-intervention in patients who have undergone pancreatico-duodenectomy (PPPD) or Whipple’s procedure.

Methods
Retrospective collection of data from a prospective database of patients who underwent PPPD or Whipple’s procedure between January 2017 and February 2021.
Serum CRP was collected from day one to day five post-operatively, and day three or the closest available result of post-surgery drain amylase values were considered. Cutoff values were determined as follows: day three CRP optimal level was determined by the median (175 mg/L), and drain amylase was determined by three times the upper limit of normal serum amylase level (330 U/L).
Post-operative pancreatic fistulas (POPF) were classified as per the 2016 International Study Group for Pancreatic Surgery (ISGPS). Re-intervention was defined as any deviation from the normal post-surgical care – including interventional radiology procedures, embolisation, re-look laparotomies and re-admission to Intensive Care.

Results
A total of 217 patients were included in this study – 182 underwent pylorus preserving pancreaticoduodenectomy as opposed to those who had Whipple procedure. 55 (25%) patients required re-intervention post-operatively. A day three CRP above 175 showed a sensitivity of 78% and specificity of 66% in predicting re-intervention in these patients. The combination of this and elevated drain amylase proved to be more sensitive (85%) and specific (87%) than the CRP alone.

Conclusions
Day 3 CRP and drain amylase are accurate predictors of post-PPPD and Whipple’s re-interventions. We aim to include this as part of the local Enhanced Recovery Pathway to help identify patients that will potentially develop complications requiring further surgical management.
P-P46 The use of FDG-PET/CT in the pre-operative staging of pancreatic ductal adenocarcinoma
Authors: Jordan Rebecca , Muir Duncan , van Laarhoven Stijn , Falk Stephen , Strickland Andrew , Skipworth James 
Published: December 2021

Abstract

Background
The NICE Quality Standard for Pancreatic Cancer (December 2018) recommends that ‘adults with localised pancreatic cancer on CT(should) have staging using fluorodeoxyglucose positron emission tomography/CT(FDG-PET/CT) before they have surgery, radiotherapy or systemic therapy’. Such FDG-PET/CT staging aims to provide additional information to conventional cross-sectional imaging, thus presenting the most accurate staging of disease. However, the sensitivity and specificity of FDG-PET/CT to deliver relevant additional clinical information must be balanced with potential delays to treatment, and additional cost associated with its use, in the management of a time-critical pathology.

Methods
Consecutive pancreatic ductal adenocarcinoma(PDAC) patients deemed resectable on conventional imaging, and therefore referred for FDG-PET/CT assessment, were included for analysis. Data were derived from a single tertiary Hepatopancreaticobiliary(HPB) centre between May 2018 and June 2021. Data were collected and analysed from a combination of prospectively-collated electronic databases and paper patient records.

Results
Of 89 patients analysed, 55(61.7%) patients were male. Primary pancreatic lesions were PET avid in 81 cases(91%). Median time from request to FDG-PET/CT performance was 11 days(Range 1-35).
Additional clinical information from FDG-PET/CT was provided in 61(68.5%) patients. Further investigations to assess FDG-PET/CT findings were arranged in 23 patients(25.8%; including liver MRI and EUS), demonstrating that FDG-PET/CT findings were true-positive in 6(26.1%), false-positive in 15(65.2%) and equivocal in 2(8.7%). There was a median delay of 60.5 days(Range 26 to 256) from FDG-PET/CT to surgery in those undergoing additional investigation. In total, a new diagnosis of metastatic/non-resectable disease was made in 14(15.7%) patients, preventing progression to planned operative intervention.

Conclusions
FDG-PET/CT provided additional information to conventional imaging that led to cancellation of planned operative resection in 14(15.7%) PDAC patients-8 directly and 6 following further investigation. However, there was a median delay of 11 days to FDG-PET/CT and 60.5 days from FDG-PET/CT to surgery in those undergoing additional investigation.
Whilst FDG-PET/CT can lead to avoidance of unnecessary surgical intervention in PDAC patients with unsuspected metastatic/non-resectable disease, it can lead to delay, over-investigation, excess cost and anxiety in resectable patients. HPB units should audit their own findings to assess whether the use of FDG-PET/CT should be considered on a standard or selected basis.
P-P51 Assessing the severity of pre and post-operative malnutrition in cancer patients undergoing pancreaticoduodenectomy: A review of a virtual dietetic prehabilitation service
Authors: Cox Leah 
Published: December 2021

Abstract

Background
The prevalence of malnutrition amongst pancreatic cancer patients is widely reported. This is due to reduced nutritional intake, increased energy expenditure and increased nutrient losses secondary to malabsorption. A Whipple's procedure or pancreaticoduodenectomy is the only potentially curable intervention for pancreatic cancer patients. Malnutrition is associated with increased peri and post-operative complications including delayed wound healing, longer hospital admission and higher mortality rate. Dietetic prehabilitation is a proactive intervention to assess patients’ nutritional status in preparation for elective surgery and, through early dietetic intervention, has the potential to improve perioperative outcomes. This pilot study reviewed the severity of nutritional risk in both the pre and post-operative stages to understand the need for dietetic prehabilitation in this patient group.

Methods
All patients referred were nutritionally assessed as part of a dietetic cancer prehabilitation pathway, which includes pre-surgical nutritional assessment within one week of referral and early post discharge nutritional assessment. Nutritional assessment was carried out using the PG-SGA short form and patients were triaged as requiring either a universal, targeted or specialist dietetic intervention dependent on severity of nutritional risk. Patients who scored &lt;4 were triaged as universal, and were low nutritional risk. Patients who scored 5-9 were triaged as targeted and were medium nutritional risk, and patients who scored &gt;9 were triaged as specialist, and were high nutritional risk.

Results
35 patients were referred for dietetic prehabilitation assessment. 71% of patients were triaged as requiring either a targeted or specialist prehabilitiation intervention. BMI ranged from 15.7kg/m² to 35.9kg/m² and median weight loss was 10.0%. 23 patients received early post surgical nutritional assessment, within 12 days of discharge from hospital. All 23 patients required targeted or specialist dietetic intervention. 22 patients reported post-operative weight loss, with a median weight loss of 7.5%. There was no correlation between pre-surgical and post-surgical nutritional risk.

Conclusions
Patients undergoing pancreaticoduodenectomy are at high nutritional risk in both the pre and post-operative periods. Patients without evidence of malnutrition in the pre-operative stage remain at high risk of malnutrition and the associated complications in the post operative stage. A prehabilitation programme can identify patients at nutritional risk and institute interventions to optimise perioperative nutritional status. Findings from this review will form the basis of a study examining the effects of a prehabilitation programme on outcomes following pancreaticoduodenectomy.