bluuebunny/crossref_metadata_2025_split huggingface dataset:
HPB P32 Ablative techniques in Colorectal Liver Metastases: A Systematic Review and Descriptive Summary of Practice
Authors: Han Ng Wee , Machado Catarina , Rooney Alice , Jones Robert , Rees Jonathan , Pathak Samir 
Published: November 2023

Abstract

Background
In the UK, over 40,000 patients are diagnosed with colorectal cancer annually. Many of these patients develop liver metastases. Although surgical resection is the gold-standard treatment for colorectal liver metastasis (CRLM), some patients are unsuitable for resection. Radiofrequency Ablation (RFA) and Microwave Ablation (MWA) are alternative treatments for CRLM. However, consensus is lacking regarding selection criteria, tumour characteristics, ablation technique delivery, and device settings. This systematic review summarises current evidence regarding selection criteria, treatment indications, and ablation delivery to inform future prospective studies.

Methods
A systematic review was conducted following PRISMA guidelines. Studies assessing RFA and MWA treatment of CRLM were identified in Medline, Embase, Web of Science and the Cochrane database of systematic reviews, from inception until 1st June 2021. Eligible studies included those reporting patient selection, tumour characteristics, treatment delivery, ablation device settings, and ablation outcomes for CRLM. Data extraction and analysis were performed.

Results
Forty-six studies were included (retrospective cohort n=40, prospective cohort n=4, non-randomized comparative studies n=2). Fifty-four inclusion criteria were used across 39 studies and were not stated in 7 studies. Tumours varied in mean number (1-8) and diameter (1.54-4.35cm). Neoadjuvant chemotherapy use (10-100% of patients), ablation delivery approach (Open n=4, laparoscopic n=11, percutaneous n=23, mixed n=2), anaesthetic mode (GA n=17, LA n=9, mixed n=2) and delivering clinician (radiologist n=8, surgeon n=15) all varied. Thirty studies lacked complete ablation device settings. Six studies followed a standardised ablation algorithm and 10 studies had specific settings. Five-year survival ranged from 0-69.7% for ablation.

Conclusions
There is significant heterogeneity in study design, patient selection, and ablation techniques for CRLM. The lack of standardized approaches and inconsistent reporting of methodology and outcomes make it challenging to determine the optimal ablative treatment for CRLM. Future research should focus on clearly defining selection and treatment criteria, as well as treatment delivery to facilitate generalisability. An RCT investigating ablation techniques may be difficult to implement due to a lack of clinician and patient equipoise, however, a high-quality, multi-centre nationwide prospective cohort study to investigate ablation as an alternative to surgery is required for high-risk patients with CRLM.
HPB P33 Evaluating the Disease Burden of Gram-negative Bacteraemia Secondary to Cholelithiasis in a Multi-site District General Hospital
Authors: Dhillon Kieran , Hughes Daniel , Veeramootoo Darmarajah , El-Kafsi Jihene 
Published: November 2023

Abstract

Background
The incidence of symptomatic cholelithiasis continues to rise. We are now observing an increasing number of cases within an elderly, frail, co-morbid patient population. Gram-negative bacteraemia (GNB) secondary to cholelithiasis in this high-risk patient cohort carries a significant morbidity and mortality rate. Reducing GNB rates has been identified as a national target by Public Health England. Our aim is to evaluate the burden of GNB due to cholelithiasis and the management received in a district general hospital in order to inform approaches to reducing the burden of GNB.

Methods
A cross-site audit was conducted across two ‘hot’ district general hospitals serving approximately 1 million people within the same NHS foundation trust. Patients with positive blood cultures for GNB secondary to cholelithiasis were identified. Data was collected regarding patient demographics, survival outcomes, whether definitive treatment for cholelithiasis was performed on the index admission and re-admission rates.

Results
A total of 176 GNB patients from a microbiology database were analysed of which 69 (39%) were identified to have gallstone disease on index admission. Median age of the cohort was 81 years old. Only 10 patients (14%) received a cholecystectomy. Previous gallstone-related admission was found in 23 patients, therefore 23/176 (13%) of GNBs were potentially preventable. Assessment of fitness found 11/176 (6%) were preventable as they were fit for surgery at index non-GNB biliary admission, 4 patients were on a waiting list. Overall, 25 patients were unfit for surgery of which 12 received a drain and 6 were readmitted.

Conclusions
This audit demonstrated a significant proportion of GNB is caused by gallstone disease however a minority of patients are receiving surgery during admission, relinquishing the opportunity to prevent readmission in surgically fit patients. With long waiting times for elective procedures, combatting the burden of GNB requires a shift towards the use of acute cholecystectomy lists. With an increasingly frail population optimal non-operative management is essential to reducing GNB burden, almost half of these patients received a drain which evidence suggests does not reduce recurrence. Greater use of cystic duct stents advised by NICE in this cohort may reduce GNB admissions.
HPB P37 Sustaining and rebuilding a laparoscopic cholecystectomy service in the COVID and post-COVID era
Authors: Dorrian Emmet , Winter Jonathan , Scoffield Julie , Jones Claire 
Published: November 2023

Abstract

Background
In the Belfast Trust (BHSCT), general surgery provision is complex- segregated into emergency and elective care, across multiple sites. The Emergency Surgical Unit (EmSU) provides ‘hot’ laparoscopic cholecystectomy (LC), and aside from a brief pause, continued throughout COVID. Elective LC was offered on another site in conjunction with the HPB service. This site became a COVID centre and surgical wards closed. Few cholecystectomies were performed during 2020/1. In an effort to restore provision, two ambulatory lists were established on the emergency site in December 2021. Subsequently, a regional ‘over-night stay’ unit opened on the original elective site in April 2023.

Methods
Previous BHSCT data demonstrated 300-350 elective LCs are undertaken annually with 66% as day cases. Since COVID, anecdotally significantly less LCs have been performed, and the length of stay (LOS) appeared greater. We performed a retrospective study looking at three time periods for comparison. “Pre-pandemic era” January 2019 to February 2020, “pandemic era” March 2020 to December 2021, and “pandemic recovery” from January 2022 to present. Patients were identified using the local HPB database and the electronic care record was reviewed for each patient. Information was gathered on demographics, day-case rate and LOS, as well as conversion and complication rates.

Results
In all, 827 patients have undergone cholecystectomy since the beginning of 2019. This is significantly less than the projected 1575, based on previous unit volume. Patient demographics are unchanged with mean age of 51.2 years, BMI of 30.27 and M:F ratio of 1:2.3. With the onset of the pandemic, we observed an increase in the average length of stay from 1.22 to 1.77 days with an associated fall in the day-case rate from 63.1% to 35.1%(figure 1). As demonstrated in figure 2, complication rates increased across the board and have been slow to fall in the recovery phase.

Conclusions
COVID decimated elective surgery globally. Locally, LC provision is an obvious example, with only urgent cases undertaken (76 in 2021 vs 363 in 2019). Unsurprisingly, conversion and complication rates increased.
Despite attempts to reinstate the service, previous volume and outcomes have not been matched for multiple reasons. Increased time to surgery (waiting list &gt;1600pts) means patients present with more severe disease. Ambulatory patients are nursed in EmSU where the environment is not orientated to rapid turnaround surgery. In addition, major losses of experienced nursing staff further impact theatre turnover and added to the challenge of setting up new elective facilities.
HPB P41 The incidence and diagnostic potential of Extra-biliary findings on Magnetic Resonance Cholangiopancreatography
Authors: Tan Chin K , Wong Mei K , Kee Ng Shou , Stevenson Carla , Shahzad Khan Khurram 
Published: November 2023

Abstract

Background
Magnetic Resonance Cholangiopancreatography (MRCP) is increasingly utilised to assess the biliary tree. This imaging modality can potentially reveal extra-biliary findings that will warrant further urgent investigations. The primary aim of this study was to assess the prevalence of extra-biliary findings on MRCPs. The secondary aim was to assess the need for subsequent investigations and subsequent outcomes.

Methods
This was a retrospective cohort study of all consecutive MRCPs performed on adult patients in a single centre form September 2021 to September 2022.
Patient demographics, indication(s) for MRCP, MRCP result including extra-biliary findings were analysed from electronic case notes. Further analysis of necessary investigations into these extra-biliary findings and outcomes was also undertaken. This study was registered with Clinical Quality Project (LanQIP 14742).

Results
495 MRCPs were performed in the study period; 305 (61.6%) were female; median age was 63 years (IQR 50-74). 311 (62.8%) were inpatient and 200 (40.4%) were urgent. 61.2% (n=303) had at least one extra-biliary finding and 8.1% (n=44) required urgent follow-up with 12 having a new diagnosis of malignancy.
19.4% (n=96) had renal cysts, 12.7% (n=63) had hepatic cysts, 5.6% (n=28) had pancreatic cysts, 2.8% (n=14) had liver cirrhosis, 2.8% (n=14) had peripancreatic collections, 3.4% (n=17) had a hiatus hernia, 7.3% (n=36) had pleural effusions, 5.3% (n=26) had splenomegaly and 1.8% (n=9) had identified diverticular disease.

Conclusions
Each of the extra-biliary findings on MRCP were confirmed with further investigation, which again highlights the high accuracy of Magnetic Resonance Imaging (MRI). It is undeniable that MRCPs are revealing extra-biliary findings which indicate that the diagnosis potential of MRCPs is underestimated. Although MRIs are widely used and has no ionising radiation unlike Computerised Tomography (CT) scans, they are still more costly. Furthermore, it was also noted in previous studies that incidental findings are largely dependent on the reporting radiologist and a structured proforma might be beneficial moving forward.
HPB P44 Case Report: Retrograde transhepatic duodenal and antegrade common bile duct stenting in malignant duodenal stricture
Authors: McWade Megan , Murch Cliff , Shahzad Khan Khurram 
Published: November 2023

Abstract

Background
Duodenal adenocarcinoma is a rare and aggressive malignancy, that unfortunately often present late meaning diagnosis can be delayed and commonly have no curative surgical options available. Patients with non resectable disease typically have a life expectancy from 2-8 months. In these palliative patients, antegrade stenting of the malignant stricture can effectively relieve symptoms of gastric outlet obstruction. We present retrograde transhepatic duodenal stenting in a patient where antegrade stenting had failed.

Methods
A 68 year old woman presented with abdominal pain, vomiting and weight loss, was found to have gastric outlet obstruction on imaging and subsequently diagnosed with D1 duodenal adenocarcinoma. Multiple attempts at dilatation had failed and one failed attempt at antegrade stenting to relieve their symptoms. A novel technique of retrograde transhepatic stenting of duodenal stricture and antegrade common bile duct (CBD) was then successfully performed with no post procedure complications. Not only did this help alleviate the patients’ symptoms but allowed subsequent antegrade passage of a D3 stent from a subsequent obstruction.

Results
Retrograde transhepatic duodenal stenting was carried out under general anesthesia with a right percutaneous puncture to pass a guide wire into the intrahepatic ducts, then the CBD narrowing followed by the duodenal stricture. The duodenal stricture was then stented followed by the CBD stricture and a drain left in the common hepatic duct.

Conclusions
Although duodenal adenocarcinoma is rare, it should be considered in all patients with suspected gastric outlet obstruction. A multidisciplinary team approach is necessary in managing patients with duodenal strictures. Retrograde transhepatic duodenal should be considered in palliative patients when antegrade stenting fails.
HPB P50 A comparison of layered vs mass closure in development of incisional hernia following Kocher’s incision for open cholecystectomy, a retrospective analysis
Authors: Korolchuk Mykola , Azam Muhammad , Satchidanand Rajesh 
Published: November 2023

Abstract

Background
Incisional hernias are a common complication of abdominal surgery. Open cholecystectomy procedures predispose to development of incisional hernias. Studies have shown rates of incisional hernias in visceral abdominal surgery to be 12.6% at one year and 22.4% at 3 years [1]. Several techniques have been developed to reduce rates of incisional hernia, namely abdominal wall closure in layers rather than mass closure. The purpose of our study is to evaluate whether layered closure is superior in preventing incisional hernias compared to mass closure.

Methods
The study reviewed retrospective data on 694 cholecystectomies at Southport or Ormskirk NHS Trust between 2018-23. Of these cases, 104 underwent open procedures. Operation notes and follow up were accessed electronically and analysed. Patients were also contacted by telephone to further establish whether they have developed incisional hernias and discuss other complications following surgery. The primary objective was to compare hernia rates between mass and layered closure. Secondary objectives were to establish hernia incidence in relation to gender, age, BMI, and elective vs emergency surgery.

Results
Of the data analysed, there was an equal proportion of male and female patients. Median age of patients was 62. Median BMI of all patients was 29 and median BMI of those developing hernias was 37. 80.8% of open cholecystectomies were elective procedures and 19.2% were emergency procedures. Infection rate was found to be 3.8%, and 30-day mortality was 1.9%. The mean rate of incisional hernia was 7.7% with mean rates of mass and layered closure at 2.7% and 11.1%, respectively. Fisher’s exact test showed that there was no statistical significance in closure method on hernia development.

Conclusions
We found no statistical significance in incisional hernia development between mass and layered closure in open cholecystectomies. No statistical significance was seen in hernia development with relation to age, gender and elective vs emergency surgery, however greater BMI was found to be statistically significant in increasing risk of hernia development. Larger, prospective multi-centre data are needed to further evaluate these results and aid surgeons in choosing an optimal closure technique in the future.
HPB P51 One hundred consecutive pancreaticoduodenectomies performed by a newly appointed consultant surgeon: perioperative clinical outcomes
Authors: Patel Bhavik , Dennison Ashley , Arshad Ali 
Published: November 2023

Abstract

Background
Pancreaticoduodenectomy (PD) involves surgical resection of pathology affecting the pancreas and periampullary region. PD was historically associated with high rates of morbidity and mortality. More recently there has been a reduction in 90-day mortality (2-5% in most series), however morbidity remains high. Postoperative pancreatic fistula (POPF) remains a main source of major morbidity after PD. There is conflicting data regarding POPF and morbidity rates, which may be higher for newly appointed compared to established consultants, reflecting reduced operative exposure for senior trainees. We present a consecutive series for a newly appointed consultant surgeon, with particular attention on clinical outcomes.

Methods
Between July 2018 and April 2023, 100 consecutive pancreaticoduodenectomies were performed by a single surgeon (AA). Pancreatico-jejunostomy reconstruction was performed in all cases using a 2 layer duct to mucosa technique, reproduced from a senior surgical mentor (AD) during training. A post hoc analysis of a prospectively maintained database was performed to determine outcomes of these patients. Data collected included patient demographics, neoadjuvant therapy, intraoperative details, Pancreatic Fistula Risk Scores, morbidity details, length of stay and 90-day readmission. POPF was defined according to the latest definition by the International Study Group of Pancreatic Surgery.

Results
43 patients underwent a pylorus preserving procedure whereas 57 underwent a classic PD (M:F 3:2; median age 66 (range 20–85) years; median BMI 25.4; ASA ≥ III n=38). The mean operative time was 479 minutes; mean blood loss was 719ml and mean pancreatic duct size was 4.8mm. 13 patients underwent portal vein resection. Median hospital stay was 8 days (range 5–35). Clinically significant pancreatic fistula rate was 6% (5 Grade B and 1 Grade C). 90-day mortality was zero and major morbidity (Clavien-Dindo grade ≥ III) rate was 7%. 90 day readmission rate was 6%.

Conclusions
This case series of 100 PDs by a newly appointed consultant demonstrates clinical outcomes which are comparable to more experienced established consultants in the best performing units. These outcomes can be attributed to standardisation and reproduction of operative reconstruction technique learned during training from a senior surgical mentor, meticulous post-operative care and multidisciplinary team working at a high-volume pancreatic surgery centre. Excellent clinical outcomes from PD can be achieved by new consultant surgeons, in an era of relatively diminished surgical exposure during training, by following these tenets.
HPB P52 Castleman Disease in Hepato-pancreaticobiliary Surgery: Friend or Foe?
Authors: Govindu Emeema , Florou Evangelia , Fernandez-Pujol Andrea , Shankar Sadhana , Evangelos Prassas 
Published: November 2023

Abstract

Background
Castleman disease is a rare lymphoproliferative disorder with low malignant potential. It is associated with risk of lymphoma & follicular dendritic cell tumours. The disease is poorly understood and is well noted in literature, the difficulty in reaching to a diagnosis. While the systemic form of the disease is a subject of Hematological work up, the unifocal disease usually consists of radiologically detected retro-peritoneal or mesenteric masses posing diagnostic challenge to hepato-pancreatico-biliary surgeons.

Methods
Over a period of 12 years, from 2011 till 2023, in our institution we have identified 4 cases of Castleman disease. Median age of is 60 yo with equal incidence in both sexes. In our series, in all four cases, the diagnosis was incidental while they were being worked up for other conditions. In fact, in 1 case the diagnosis was unexpected after surgery for other reason. Extensive work up including cross-sectional imaging studies failed to reach a diagnosis, therefore, the latter was established by excision.

Results
All four patients underwent resection that accomplished diagnosis.Three patients underwent surgery for primary excision of the tumour located in various sites of upper abdomen; one para-duodenal, one retro-hepatic and one aorto-caval. In one case, the nodule was a FDG-PET avid mesenteric mass resected in the context of planned Whipple’s procedure for cancer. The Histopathological examination confirmed diagnosis in all cases. Haematology follow-up was recommended in two cases one of which progressed to follicular dendritic cell tumor. All patients were HIV negative and HHV-8 negative. The longest follow-up is 12 years with no evidence of recurrence.

Conclusions
Castleman’s disease is a rare entity with very low malignant potential. Cases with unifocal disease in upper abdomen are referred to Hepato-pancreato-biliary surgeons and resection is the treatment of choice. The latter allows histopathological analysis establishing the diagnosis. This case series is useful to all HPB surgeons who may come across this diagnostic challenge for this poorly understood pathology.
HPB P58 Laparoscopic cholecystectomy as a training case in the post-Covid world
Authors: Hussain Muhammad , Asarbakhsh Mariam , Singh Gautam , Routledge Jamie , Wijayendran Anusan , Sowemimo Sinmidele , Saha Arin 
Published: November 2023

Abstract

Background
Laparoscopic cholecystectomy is an index procedure for all higher surgical trainees, regardless of sub-specialty. Minimum numbers and evidenced ‘Level 4’ competency are necessary for successful completion of training. The Covid-19 pandemic led to falls in training opportunities, during the acute phase itself and in the current drive to reduce elective waiting lists. More cases are outsourced and those cases that are being performed in the NHS may be more complex due to longer waiting times. These twin pressures have led to concerns that training opportunities for laparoscopic cholecystectomy are being limited. This study evaluated the training opportunities for laparoscopic cholecystectomy.

Methods
All patients who had laparoscopic cholecystectomy over a four-month period, from January 2023 to April 2023 were identified from a prospectively maintained database of operations. Electronic patient records were interrogated to gather pre-operative data (symptomology, co-morbidities, acuity of presentation, pre-operative investigations), intra-operative findings and progress (grade of primary surgeon, nature of operation) and post-operative outcomes and complications. Factors which were associated with the case being performed by a trainee were assessed, as well as differences in outcomes between consultant and registrar procedures.

Results
There were 150 laparoscopic cholecystectomies performed during the study period. 79 (53%) of these cases were performed acutely ('hot' gallbladders). Registrars performed 36 elective laparoscopic cholecystectomies (51%) and 42 acute cases (53%). Operating time was comparable between registrars and consultants (median operating time [registrar vs. consultant], 72 vs. 78 minutes). There were no particular pre-operative factors that predicted a case being performed by a trainee. There were no differences in post-operative outcome or complication between grade of primary surgeon; there were no bile duct injuries. There were three patients who had a return-to-theatre (2 registrar, 1 consultant case).

Conclusions
The current case mix in our hospital has meant that just over half the laparoscopic cholecystectomies performed were completed by a trainee. Not a single case was performed by an 'SHO' level surgeon, suggesting that this operation is now the preserve of higher surgical trainees. Without a high-functioning acute gallbladder service, training opportunities for this operation would be severely limited. It is safe to train laparoscopic cholecystectomy, even in the acute setting, and more should be done to identify factors which could improve training opportunities.