bluuebunny/crossref_metadata_2025_split huggingface dataset:
HPB P28 Continuous glucose monitoring improves the diagnosis of insulinoma and surveillance after endoscopic ablation therapy
Authors: Thorne Rebecca , Kowal Mikolaj , Anthoney Alan , Huggett Matthew , Shapey Iestyn 
Published: November 2023

Abstract

Background
Insulinomas are the most common functioning pancreatic neuroendocrine tumours (PNET) and are classically diagnosed according to Whipple’s triad. The gold-standard diagnostic test (72 hour fasting glucose/C-peptide) is difficult for patients, and risks mis-diagnosing patients who only experience post-prandial symptoms. Moreover, the advent of endoscopic ablative techniques means that confirming successful treatment can be challenging when compared with surgical resection. This study aimed to investigate the value of continuous glucose monitoring (CGM) to: a) confirm the diagnosis of insulinoma; b) guide symptom management whilst awaiting definitive treatment; and c) as a surveillance tool in patients electing for non-surgical interventions.

Methods
A 61-year-old healthy male presented with post-prandial sweating, vacant episodes and reduced exercise tolerance which resolved upon consuming glucose. Computed Tomography demonstrated a 2cm exophytic hypervascular lesion in the pancreatic body, consistent with a NET, and correlated with an Octreotide avid lesion upon SPECT/CT. Overnight fasting glucose/c-peptide was not confirmatory. The target glucose range was defined as 4.0-9.9 mmol/L and critical hypoglycaemia as ≤2.9mmol/L. Data from CGM were analysed (Time in range and critical hypoglycaemia [Chi2]; glycaemic control and glycaemic variability [T-test]) during diagnosis, in the first week post-ablation, and the recovery phase beyond 3 weeks.

Results
Data from 22,008 glucose levels were analysed over a 90 day period. Time in range during diagnosis was 67.25%, 82.8% (p&lt;0.0001) post-ablation, and 98.9% (P&lt;0.0001) during recovery. Critical hypoglycaemia occurred in 5.2% of measurements during diagnosis, 1.9% (p&lt;0.0001) post-ablation, and 0.1% (p&lt;0.0001) during recovery. Glucose levels (mean [SD] mmol/L) were 4.4 (0.47) during diagnosis, 4.9 (0.29) (p=0.0001) post-ablation, and 5.7 (0.42) (p&lt;0.0001) during recovery. Glycaemic variability (mean [SD] %CV) was 19.4 (5.09) during diagnosis, 20.17 (5.60) post-ablation (p=0.630), and 11.3 (5.53) (p&lt;0.0001) during recovery. Temporal changes identifying post-prandial hypoglycaemia during diagnosis, and resolution during recovery, are illustrated (Figure 1).

Conclusions
CGM has utility to accurately diagnose insulinoma when standard tests are negative, and to improve quality of life by alerting patients to life-threatening critical hypoglycaemia. As parenchymal preserving non-operative therapies increase in popularity, especially for patients with small PNETs, sensitive, reliable, and acceptable surveillance techniques are required in order to confirm treatment success and monitor for recurrence. Proactive engagement with commissioning and regulatory bodies is necessary in order to harness the potential from emerging technologies, so that PNET patients can benefit in a similar manner as those with type 1 Diabetes Mellitus.
HPB P29 Improving the management of pain and cachexia in pancreatic cancer: Development of a patient-centred evidence-based pathway
Authors: Postaleniec Emilia , Roberts Danielle , Puthiyakunnel Saji Alwin , Selvakumar Jashan , Haghighat Ghahfarokhi Mahta , Davidson Brian , Gurusamy Kurinchi 
Published: November 2023

Abstract

Background
Incidence of pancreatic cancer is increasing worldwide and is likely to become the third commonest cause of cancer death in UK by 2030. Approximately 75% of people with pancreatic cancer suffer with pain and over 50% have cachexia (weakness and wasting of the body). However, there is considerable uncertainty regarding management of these distressing symptoms. We aim to identify the best interventions through systematic reviews and meta-analyses; and then will perform surveys and focus groups to reach a consensus in development of a care pathway that is acceptable to patients and ready to assess for feasibility of introduction in NHS.

Methods
We will compare the relative benefits and harms of different interventions for pain in unresectable pancreatic cancer and for prevention and treatment of cachexia due to pancreatic cancer, through systematic reviews (SR) and network meta-analysis. Data obtained will feed into two online surveys. (1) Patients/carers will rank interventions (identified from SR) in order of preference/acceptability. (2) Healthcare professionals will score interventions (identified from SR) on scale 1-10 according to feasibility of delivery in NHS. Four focus groups will be conducted to evaluate findings and discuss areas of contention, to enable consensus in the development of the care pathway.

Results
Project is currently in progress. Funding was awarded from April 2022 (NIHR202727). Both systematic review protocols were prospectively registered on PROSPERO in May 2022 (CRD42022333239/CRD42022333241). Approval by University College London Research Ethics Committee (23563/001) was received in December 2022. Data analysis is underway, expected to end by October 2023. Surveys and focus groups will be conducted thereafter. The online surveys will be primarily distributed via Pancreatic Cancer UK, but website links will also be made available on the PROSPERO records. The project is due to end in April 2024 and results will be published within 12 months of project completion.

Conclusions
This will be the first systematic review and network meta-analysis on these topics, thus enabling multiple treatment comparisons, additive effects and interaction models for different treatment combinations. We will also identify gaps in existing research that cause uncertainty in decision-making in management of pain and cachexia in pancreatic cancer. Through the surveys and focus group discussions, key stakeholders including patients, carers, and healthcare professionals, will facilitate the development of an evidence-based care pathway, ensuring both end-user acceptability and feasibility of delivery within NHS. Findings will be disseminated through patient group websites, conferences, and publication, irrespective of results, in peer-reviewed journals.
HPB P42 Case Report: Laparoscopic Cholecystectomies in patients with a Ventriculoperitoneal shunt: key considerations for surgeons
Authors: Ali-Qazalbash Zeeshan M , Bisset Carly N , Shahzad Khan Khurram 
Published: November 2023

Abstract

Background
Laparoscopic surgery has evolved to become the preferred mode of access for intraperitoneal surgery and is the gold standard approach to cholecystectomy. With the high prevalence of laparoscopic procedures to definitively treat gallstones and their associated complications, an increasing number of patients with co-morbidities are undergoing these procedures, including patients with cerebrospinal fluid (CSF) shunts in situ. These shunts pose unique challenges due to the paucity of guidelines, research and data to optimally manage these patients.

Methods
We report a case of a patient who underwent a successful, but technically challenging laparoscopic cholecystectomy whilst having a Ventriculoperitoneal (VP) shunt present. Important considerations are necessary, including the additional risks of: shunt failure and impaired CSF drainage, retrograde insufflation leading to increased intracranial pressure and herniation, and the risk of bile leak which could result in ascending meningitis (thereby making intra-operative cholangiogram a relative contraindication). We will discuss what unique measures were implemented pre-operatively, peri-operatively and post-operatively to prevent these complications, in consultation with both the patient and the wider multidisciplinary healthcare team.

Results
A 39-year-old female with gallstone pancreatitis, underwent an ERCP, and was subsequently listed for elective laparoscopic cholecystectomy. From childhood, she had a VP shunt in place for an Arnold Chiari II malformation. A literature review was conducted and a CT scan was arranged. Her case was discussed with neurosurgery, radiology, microbiology and anaesthetics, with multiple safety recommendations proposed; including US guided marking of the shunt tubing on the skin, appropriate pre-operative antibiotics, lower than normal pneumoperitoneum pressures, no attempt at intra-operative cholangiogram or bile duct exploration, avoidance of gallbladder perforation, minimal washout, neuro-observations in the post-operative period and post-operative antibiotics.

Conclusions
Our report shows that with thorough pre-operative planning involving communication with multidisciplinary team and with informed consent, laparoscopic cholecystectomy can be performed in this patient sub-group with relative safety without the need for shunt manipulation or peri-operative intracranial pressure monitoring. It is however, technically challenging, and should be considered by experienced laparoscopic surgeons, and perhaps reserved for those with subspecialty biliary interests.
HPB P43 Pancreatic Anastomosis Audit (PARANOIA): Initial experience of an international POPF registry
Authors: Pande Rupaly , Roberts Keith ,   Paranoia Study Group
Published: November 2023

Abstract

Background
Post-operative pancreatic fistula (POPF) remains the primary determinant of poor outcome following pancreatoduodenectomy (PD) Risk factors are well understood but there is no apparent reduction in incidence. RCT’s are methodologically flawed to investigate POPF.
PARANOIA is a registry with two novel outcomes. 1) Surgeons-specific risk-adjusted outcomes: Surgeons will observe in real time how changes to surgical technique impact upon outcomes. By having access to the registry data surgeons can explore technical factors of pancreas surgery that are associated with high or low risk of pancreatic fistula. 2)The registry will serve as a platform for international prospective studies.

Methods
Core dataset consists of common risk factors found within scores (aFRS, FRS, Roberts’) along with anastomotic technique and adjuncts. Initial prospective studies test topical clinical questions through embedded parallel studies. Using a stepwise approach, the registry and user network will be tested with increasingly complex study designs to determine the functionality of the registry as a novel research tool. Surgeons will have their risk-adjusted outcomes as a CUSUM plot which they can compare against anonymised surgeons by different variables.

Results
232 registered surgeons across 56 countries with 776 cases. Majority of surgeons are performing open surgery (open 208 (89.7%) vs laparoscopic (11 (5.2%) vs robotic 11 (5.2%)). End-to-side was the commonest technique (88.8%) with invagination (69%) being used more than duct-to-mucosa (31%). 43.5% of surgeons used an internal stent routinely and almost all used drains (97.8%). 13% used pharmaceutical sealants whereas 28.4% used an autologous barrier. 44% used a somatosatin analogue (SSA). 70.5% reported no POPF whereas 8.4% had a CR-POPF rate. A reduced CR-POPF was associated with use of stent (p=0.008), autologous barrier (p=0.012) and SSA (p=0.049).

Conclusions
The PARANOIA registry has shown rapid recruitment of surgeons and data entry in pancreatic surgery can not only shorten the timeframe from study conception to dissemination of results but also provide real world data and provide comparison of outcomes between and within geographical regions, a key factor given that some patient and operative variables relevant to POPF vary across the globe. Registry data and the risk-adjusted CUSUMS can be used by surgeons to benchmark themselves against their peers and consider how modifications to their operative technique or perioperative care may affect their outcomes.
HPB P54 First Reported Case of Primary Serous Cystadenocarcinoma of the Spleen
Authors: Sciberras Peter , Wilkins Alexander , Baitule Amey , Buchanan Alex 
Published: November 2023

Abstract

Background
Tumours of the spleen are uncommon, and the majority are metastases from primary malignancies in other organs. The two main subdivisions of primary malignancies of the spleen are lymphoid and non-lymphoid. Primary splenic cystadenocarcinomas are extremely rare, and only tumours of the mucinous subtype have been recorded. The spleen usually exhibits secondary infiltration from primary cystadenocarcinomas in other organs such as the ovaries and pancreas.

Methods
We present the case of an elderly white female who was found to have an incidental splenic tumour. This showed interval increase in size on serial imaging and was confirmed to be a complex mass with a cystic component on MRI. After MDT discussion and further investigations, including FDG-PET, EUS and diagnostic laparoscopy, she underwent a distal pancreatectomy, partial gastrectomy and splenectomy for a presumed tail of pancreas adenocarcinoma.

Results
The splenic hilum contained a large partly cystic tumour conglomerate measuring up to 5.8cm in maximum dimension, which contained thick, dark red, gelatinous material. It was well-circumscribed and demarcated from the rest of the splenic parenchyma, and the distal pancreas appeared to be uninvolved. Histology showed low columnar to cuboidal cells with moderate to patchy marked nuclear pleomorphism, and no cytoplasmic mucin was identified. The tumour had a predominantly papillary and focal tubular architecture, with hierarchical branching of papillae. The neoplastic cells stained positive for CK7, ER and WT1 expression and negative for CK20 and CA.

Conclusions
Histological and immunohistochemical analyses were consistent with the first recorded case in the literature of primary serous cystadenocarcinoma of the spleen, which we believe developed through malignant transformation of a benign epidermoid cyst. This is the commonest type of true cysts of the spleen and one which has tumorigenic potential, being able to undergo metaplasia and dysplasia. The patient remains well as per her latest follow-up with no evidence of recurrence or metastases. However, given the rarity of splenic cystadenocarcinomas, uncertainty remains on the long-term prognosis and optimal management of such cancers, including adjuvant treatment options.
HPB P59 An evaluation of local 30-day readmissions following laparoscopic cholecystectomy
Authors: Hussain Muhammad , Asarbakhsh Mariam , Gautam Singh , Jamie Routledge , Wijayendran Anusan , Sowemimo Sinmidele , Saha Arin 
Published: November 2023

Abstract

Background
Laparoscopic cholecystectomy, both elective and acute, is a commonly performed operation in general surgery. Good post-operative outcomes are important for patient physical and mental wellbeing. For example, complications can result in physical harm and abdominal pain can cause distress and anxiety. Patient anxiety can also result from symptoms which may not have a clinically significant or concerning cause. 30-day hospital readmission rates post-surgery are considered by some as a measure of quality of care. This study assessed 30-day readmissions following laparoscopic cholecystectomy at our local hospital and the investigation and management of these.

Methods
Clinical patient data software was used to obtain the details of all patients undergoing acute and elective laparoscopic cholecystectomy over a 4 month period, from January 2022 to the beginning of May 2022. Pre-, intra- and post-operative data was collated. Post-operative data incorporated the presenting complaints, investigations and management of patients re-presenting within 30 days of discharge from our hospital.

Results
150 laparoscopic cholecystectomies were performed over 4 months. There were 12 30-day readmissions (8%), 4 elective and 8 acute patients. Presenting complaints included abdominal and chest pain. Investigations included blood tests (10 patients, 83%), ultrasound abdomen (1 patient, 8.3%), CTAP or CTPA (7 patients, 58.3%), and MRCP (1 patient, 8.3%). CTPA scans were negative for pulmonary emboli. 3 patients (2%) with gallbladder fossa collections were discharged with antibiotics. 2 patients (1.3%) required re-laparoscopy and washout in theatre for bile leak (no CBD injury). 1 patient (8.3%) required ERCP for a distal CBD stone. Overall, 4 patients (2.7%) required inpatient admission.

Conclusions
This study found that only a third of patients reattending within 30 days required inpatient admission, which was not unexpected. However, although most patients did not require admission, arguably the investigations performed were essential to establish this. For example, although CTPA scans did not reveal pulmonary emboli, this was a necessary investigation in the post-operative obese patient with chest pain. That said, a more effective system of triage, for example face-to-face evaluation by GPs or A&E doctors and avoidance of surgical referral without clinical assessment, is suggested to prevent inappropriate referrals, such as antibiotic skin reactions and wound bruising.
OGC P06 Oncological outcomes of patients with oligometastatic oesophagogastric cancer
Authors: Down Billy , Lakunina Svetlana , Markar Sheraz , Gordon-Weeks Alex 
Published: November 2023

Abstract

Background
A recent international expert consensus defined oligometastatic oesophagogastric cancer as the presence of no more than two liver, lung, retroperitoneal lymph node, adrenal, soft tissue or bone metastases and an 18-week period of oncological stability during chemotherapy. The number of patients who fit this criterion and whether their oncological outcome differs from those with multi-metastatic disease is unknown.

Methods
We analysed our prospectively maintained database of consecutive patients with synchronous or metachronous metastatic oesophagogastric cancer from January 2017 to December 2021. The primary outcome was median overall survival (OS).

Results
We included 502 patients with 120 patients (24%) metachronous metastases following surgical resection of primary tumour and 382 (76%) with synchronous metastases. 36 (7.2%) had oligometastatic disease. For patients with metastases at diagnosis, median OS was 7.3 months for the multi-metastatic group versus 26.8 months for patients with oligometastasis(p&lt;0.0001). For metachronous disease, median OS in multi-metastatic groups was 6.1 months versus 38.6 months for patients with oligometastasis(p&lt;0.0001). 35% of patients with metachronous oligometastatic disease underwent surgical management of their metastasis. This group demonstrated improved median OS versus those receiving systemic treatment alone (&gt;60 months versus 24.4 months; p&lt;0.038).

Conclusions
Oligometastatic oesophagogastric cancer is associated with improved oncological outcome when compared to multi-metastatic disease. Further work is needed to identify patients who will benefit from aggressive treatment of metastatic oesophagogastric cancer.
OGC P16 Pancreatic Exocrine Insufficiency after Oesophagogastric Resection: Results from a Systematic Review and Meta-Analysis
Authors: Hall Lewis , Powell-Brett Sarah , Halle-Smith James , Ward Liz , Wiggins Tom , Markar Sheraz , Roberts Keith 
Published: November 2023

Abstract

Background
Unpleasant gastrointestinal complications can affect 9/10 patients after oesophagogastric resection (OGR), and malnutrition is recognised in this cohort. Untreated pancreatic exocrine insufficiency (PEI) results in substantial patient harm and is recognised as a contributor to such symptoms. The incidence of post-operative PEI is unclear, however and the benefit of management with pancreatic enzyme replacement therapy (PERT), rarely discussed. The aim of this study was to assimilate the literature on incidence, diagnosis, and management of PEI in patients following OGR.

Methods
A systematic review of PUBMED and Embase databases identified studies investigating PEI following OG resection. A pooled analysis was performed to determine prevalence of PEI in each cohort, and benefit of PERT. Meta-analyses were performed using the software package Revman 5.4, in accordance with the recommendation of the Cochrane Collaboration.

Results
Twelve studies were included in the quantitative synthesis of PEI rate after OGR surgery. The rate of PEI after any OGR was 50.4% (95% CI: 38.3% - 62.6%) amongst 463 patients. PEI was most prevalent after total gastrectomy at 66.2% (95% CI: 44.9% - 84.9%) followed by subtotal, 46.9% (95% CI: 33.3% - 60.9%) and oesophagectomy 31.0% (95% CI: 17.0% - 46.9%) The most common diagnostic test used was faecal-elastase-1 (FE-1) (4/12 studies) reporting &lt;200 µg/g as diagnostic of PEI. Four studies reported the effect of PERT, with symptomatic benefit seen in 75.2% (95% CI: 66.9% - 82.7%).

Conclusions
PEI is common following OGR, with over half of patients developing PEI. The presence of PEI reduces quality of life, contributes to malnutrition and long-term poor health, but can be managed effectively with PERT. Future work must further define the role of PERT after OGR, considering not only nutritive and qualitative benefit, but also whether a survival advantage is conferred.
OGC P19 Peritoneal metastases from gastric cancer in a nationwide cohort: incidence, treatment and survival
Authors: Rijken Anouk , Pape Marieke , Simkens Geert , de Hingh Ignace , Luyer Misha , van Sandick Johanna , van Laarhoven Hanneke , Verhoeven Rob , van Erning Felice 
Published: November 2023

Abstract

Background
The aims of this study were to investigate incidence, risk factors and treatment of synchronous or metachronous peritoneal metastases (PM) from gastric cancer and to estimate survival of these patients using population-based data.

Methods
Patients diagnosed with gastric cancer in 2015-2016 were selected from the Netherlands Cancer Registry. The incidence of synchronous and metachronous PM were calculated. Multivariable regression analyses were performed to identify factors associated with the occurrence of PM. Treatment and survival were compared between patients with synchronous and metachronous PM.

Results
Of 2147 patients with gastric cancer, 656 (31%) were diagnosed with PM. Of these, 498 (23%) had synchronous PM. The cumulative incidence of metachronous PM in patients who underwent potentially curative treatment (n=675) was 22.8% at 3 years. A factor associated with synchronous and metachronous PM was diffuse type histology. Patients diagnosed with synchronous PM more often received systemic treatment than patients with metachronous PM (35% vs. 18% respectively, p&lt;0.001). Median overall survival was comparable between synchronous and metachronous PM (3.2 vs. 2.3 months respectively, p=0.731).

Conclusions
Approximately one third of all patients with gastric cancer are diagnosed with PM, either at primary diagnosis or during 3-year follow-up after potentially curative treatment. Patients with metachronous PM less often received systemic treatment than those with synchronous PM but survival was comparable between both groups. Future trials are warranted to detect gastric cancer at an earlier stage and to examine strategies that lower the risk of peritoneal dissemination. Also, specific treatment options for patients with gastric PM should be further investigated.