bluuebunny/crossref_metadata_2025_split huggingface dataset:
HPB P22 Improving Time to ERCP for Acute Gallstone Cholangitis Admissions at a District General Hospital: A Closed Loop Audit
Authors: Boyce Louis , Kaldas Fouad 
Published: November 2023

Abstract

Background
The National Institute of Health and Care Excellence (NICE) guidelines recommend that adults with acute gallstone cholangitis receive endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours of diagnosis, especially in the moderate-severe cases. Early intervention is associated with improved patient outcomes. For smaller district general hospitals with limited resources, achieving these targets can be difficult. We audited our management of patients admitted with obstructive gallstone disease (cholangitis and pancreatitis) with aim of improving timely access to ERCP.

Methods
We performed a closed loop audit investigating time to ERCP in patients admitted with acute gallstone cholangitis at a UK district general hospital. Severity was graded according to the 2018 Tokyo Guidelines. Data was collected over a 5-month period (01/05/2023 to 01/10/2023), analysed and presented to the surgical multi-disciplinary team. Additional referral pathways to 3 nearby tertiary care centre for ERCP were established. Post-intervention admissions were re-audited over a second 5-month period (01/01/2023 to 01/06/2023) to assess the effect of the new referral pathways.

Results
Forty-one patients received ERCP for acute gallstone cholangitis (14 mild cases; 17 moderate; 10 severe). Pre-intervention, overall median time to ERCP was 10 days (5–24). For moderate-severe and mild cases median times to ERCP were 8 (5–19) and 28 days (9–46), respectively. The new referral pathways reduced overall median time to ERCP to 6 days (4–9). For moderate-severe and mild cases, post-intervention median times to ERCP were 6 days (6–8) and 4 days (4–25), respectively. Median length of stay pre- and post-intervention was 8 (6–13) and 7 days (4–10), respectively.

Conclusions
The management of acute gallstone cholangitis poses a significant burden on district general hospitals, particularly those with limited resources. By establishing additional referral pathways to nearby tertiary care centres, we successfully reduced median time to ERCP for local patients with moderate-severe acute gallstone cholangitis. This change may have may have also contributed to a reduction in overall length of stay and shorter waiting times for ERCP in mild cases of gallstone cholangitis. These findings underscore the importance of collaborative efforts between district general hospitals and tertiary centres to enhance patient outcomes.
HPB P23 Investigating the effect of N-acetylcysteine on outcomes following liver resection: A systematic review and meta-analysis
Authors: Wong Tiffany , Koh Amanda , Brutkowska Aleksandra , Gull Sadaf , Adiamah Alfred , Sanyal Sudip 
Published: November 2023

Abstract

Background
N-acetylcysteine (NAC), classed as an essential medicine by WHO, is an antioxidative agent that facilitates the conjugation of toxic metabolites. In the recent years, NAC has been routinely used to limit ischaemia-reperfusion injury during liver transplantation. There remains, however, a scarcity of large high-quality trials investigating its effectiveness in reducing post-hepatectomy liver failure and associated complications in patients undergoing liver resection. This systematic review and meta-analysis of randomised controlled trials (RCTs) aims to review the effectiveness of NAC in improving postoperative surgical outcomes following liver resection.

Methods
A comprehensive search of the MEDLINE, EMBASE, and Cochrane electronic databases was performed to identify relevant RCTs published between 1947 and December 2022. The outcomes of biochemical markers at post-operative day 1 (lactate, ALT, and INR), length of hospital stay, transfusion rates, and morbidity were extracted from the included studies. Quantitative pooling of the data was based on the random effects model.

Results
Five RCTs reporting on 388 patients undergoing liver resection met the inclusion criteria and were included in the analysis. There were no significant differences in patient demographics between groups. The postoperative lactate was lower in patients receiving NAC (WMD -1.08, 95% CI -1.54 to -0.62, I2= 0%). However, there were no differences in the postoperative INR (WMD 0.02, 95% CI -0.18 to 0.22, I2= 84%) and ALT (WMD -94.94, 95% CI -228.46 to 40.38; I2= 97%). More importantly, there were no statistically significant differences in the length of hospital stay, transfusion rates, and morbidity between the two groups.

Conclusions
This meta-analysis of RCTs has shown that the administration of NAC in patients undergoing liver resection did not alter important biochemical parameters suggesting any real effectiveness in reducing post-hepatectomy liver failure. There were no improvements in the clinical outcomes of length of stay, transfusion rates, and overall morbidity.
HPB P24 Quality assurance within multicentre randomised controlled trials of surgical interventions for pancreatic cancer: a systematic review
Authors: Helliwell Jack , Rozwadowski Sophie , Yi Kwan Jing , Bautista Melissa , Blencowe Natalie , Smith Andrew , Pathak Samir 
Published: November 2023

Abstract

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

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

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

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

Abstract

Background
Many emerging therapeutics fail to provide patient benefit due to unpredictable drug delivery and clearance following clinical translation. Normothermic machine perfusion (NMP) can preserve physiological processes in human-sized organs ex vivo, which may facilitate preclinical characterisation of pharmacokinetics and drug delivery.
The performance of ex vivo human and porcine clearance organs (liver, kidney and spleen) to 1) predict human drug pharmacokinetics and 2) assess the delivery of emerging therapeutics was investigated. A small molecule chemotherapy (irinotecan) with well-established pharmacokinetics was delivered to determine the former. Nanotherapeutics and viral vectors, two classes of emerging therapeutics, were delivered to determine the latter.

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

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

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

Abstract

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

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

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

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

Abstract

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

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

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

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

Abstract

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

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

Results
Seven male patients aged 57 to 75 had type C PPH. Symptom onset including melaena and haematemesis was between 24 hours to 38 days.
The time to CT from the request was between one to six hours. One patient was bleeding from the gastroduodenal artery stump. The other six patients had no obvious bleeding point identified. Of the seven patients, five had bleeding points identified on angiograms done by IR and underwent embolization. One patient returned-to-theatre for a re-look laparotomy. Two of seven patients died within one year of PPH. One had repeated PPH and had embolization multiple times.

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

Abstract

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

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

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

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

Abstract

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

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

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

Conclusions
In this snapshot study of liver resections over a two-year period we did find an expected bigger increase in tumour size in patients where the interval between last cross-sectional imaging and actual resection was longer. The ≥6week interval group seems to have more tumour recurrence but this did not impact overall survival. This pilot cohort was not powered to firmly establish guidance for maximum interval between last scan and surgery, but it prompts further investigation to get clarity to guide clinical practice. A larger cohort would ideally look at HCC and CRLM separately.