A multicentre prospective evaluation of health-related quality of life and patient related outcomes in pancreatic and peripancreatic cancer: PROMCAN study

BACKGROUND

The temporal evolution of HRQoL and the importance of other PROs to patients, following resection for pancreatic and peripancreatic malignancy remains unexplored.

METHODS

Patients undergoing pancreatic resection between 2021 and 2022 were enrolled from 2 UK HPB centres. Patients completed the EORTC QLQ-C30, QLQ-PAN26 tools and rated 56 PROs preoperatively (T1), at discharge (T2), 6-weeks (T3), 3-months (T4) and 6-months (T5) postoperatively. ANOVA followed by post-hoc analysis was used to examine patterns in HRQoL through time. Multivariable ANOVA was used to identify impact of clinical factors on HRQoL.

RESULTS

63 patients were recruited [median age, 72 (IQR 41-85); 39/63 male]. Physical functioning declined from 70.4 (26.2) at T1 to 53.5 (20.9) at T2 (p = 0.016). Global QoL score increased significantly from 41.0 (23.0) at T2 to 60.0 (26.1) at T5 (p = 0.007), as did role functioning [21.1 (27.9) at T2 to 59.4 (32.8) at T5, p < 0.001]. Chemotherapy status and the postoperative complications did not significantly change HRQoL. General QoL and health were the only PROs rated as 'very important' (scores 7-9) by more than 80 % of participants at five time-points.

CONCLUSION

Recuperation of HRQoL measures is seen at 6-months postoperative and was not affected by chemotherapy or postoperative complications. Notably, PROs important to patients varied over time.

Evidence for molecular subtyping in pancreatic ductal adenocarcinoma: a systematic review

BACKGROUND

Pancreatic Ductal Adenocarcinoma (PDAC) patients exhibit varied responses to multimodal therapy. RNA gene sequencing has unravelled distinct tumour biology subtypes, forming the focus of this review exploring its impact on survival outcomes.

METHODS

A systematic search across PubMed, Medline, Embase, and CINAHL databases targeted studies assessing long-term overall and disease-free survival in PDAC patients with molecular subtyping.

RESULTS

Fifteen studies including 2731 patients were identified. Molecular subtyping was performed by RNA sequencing and Immunohistochemistry in 14 studies and by Mass Spectrometry in 1 study. Two main tumour subtypes were identified (classical and basal-like or squamous) with basal like associated with poorer outcomes. Further subtypes were identified in individual studies. Superior survival was seen with classical subtype in all other analyses that compared the classical and basal subtypes. High risk stromal subtypes were identified on further analysis of the stroma and were associated with a worse survival independent of the tumour subtype.

CONCLUSION

Molecular subtyping of PDAC specimens can identify patients with high-risk tumour biology and poor survival outcomes. Routine subtyping is limited by the cost of RNA sequencing and the volume of raw data generated which has made its translation into routine clinical practice difficult.

Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach

BACKGROUND

Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis.

METHODS

Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains.

RESULTS

From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment.

CONCLUSION

There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.

Adjuvant chemotherapy for adenocarcinoma arising from intraductal papillary mucinous neoplasia: multicentre ADENO-IPMN study

BACKGROUND

The clinical impact of adjuvant chemotherapy after resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia is unclear. The aim of this study was to identify factors related to receipt of adjuvant chemotherapy and its impact on recurrence and survival.

METHODS

This was a multicentre retrospective study of patients undergoing pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia between January 2010 and December 2020 at 18 centres. Recurrence and survival outcomes for patients who did and did not receive adjuvant chemotherapy were compared using propensity score matching.

RESULTS

Of 459 patients who underwent pancreatic resection, 275 (59.9%) received adjuvant chemotherapy (gemcitabine 51.3%, gemcitabine-capecitabine 21.8%, FOLFIRINOX 8.0%, other 18.9%). Median follow-up was 78 months. The overall recurrence rate was 45.5% and the median time to recurrence was 33 months. In univariable analysis in the matched cohort, adjuvant chemotherapy was not associated with reduced overall (P = 0.713), locoregional (P = 0.283) or systemic (P = 0.592) recurrence, disease-free survival (P = 0.284) or overall survival (P = 0.455). Adjuvant chemotherapy was not associated with reduced site-specific recurrence. In multivariable analysis, there was no association between adjuvant chemotherapy and overall recurrence (HR 0.89, 95% c.i. 0.57 to 1.40), disease-free survival (HR 0.86, 0.59 to 1.30) or overall survival (HR 0.77, 0.50 to 1.20). Adjuvant chemotherapy was not associated with reduced recurrence in any high-risk subgroup (for example, lymph node-positive, higher AJCC stage, poor differentiation). No particular chemotherapy regimen resulted in superior outcomes.

CONCLUSION

Chemotherapy following resection of adenocarcinoma arising from intraductal papillary mucinous neoplasia does not appear to influence recurrence rates, recurrence patterns or survival.

Opioid analgesia and severity of acute pancreatitis: An international multicentre cohort study on pain management in acute pancreatitis

BACKGROUND

The effect of analgesic modalities on short-term outcomes in acute pancreatitis remains unknown. However, preclinical models have raised safety concerns regarding opioid use in patients with acute pancreatitis.

OBJECTIVE

This study aimed to assess the association between analgesics, particularly opioids, and severity and mortality in hospitalised patients with acute pancreatitis.

METHODS

This prospective multicentre cohort study recruited consecutive patients admitted with a first episode of acute pancreatitis between April 1 and 30 June 2022, with a 1-month follow-up. Data on aetiology, clinical course, and analgesic treatment were collected. The primary outcome was the association between opioid analgesia and acute pancreatitis severity, which was analysed using univariate and multivariate analyses.

RESULTS

Among a total of 1768 patients, included from 118 centres across 27 countries, 1036 (59%) had opioids administered on admission day, and 167 (9%) received opioids after admission day. On univariate analysis, moderately severe or severe acute pancreatitis was associated with male sex, Asian ethnicity, alcohol aetiology, comorbidity, predicted severe acute pancreatitis, higher pain scores, longer pain duration and opioid treatment (all p < 0.001). On multivariate analysis, comorbidity, alcohol aetiology, longer pain duration and higher pain scores increased the risk of moderately severe or severe acute pancreatitis (all p < 0.001). Furthermore, opioids administered after admission day (but not on admission day) doubled the risk of moderately severe or severe disease (OR 2.07 (95% CI, 1.29-3.33); p = 0.003). Opioid treatment for 6 days or more was an independent risk factor for moderately severe or severe acute pancreatitis (OR 3.21 (95% CI, 2.16-4.79; p < 0.001). On univariate analysis, longer opioid duration was associated with mortality.

CONCLUSION

Opioid treatment increased the risk of more severe acute pancreatitis only when administered after admission day or for 6 days or more. Future randomised studies should re-evaluate whether opioids might be safe in acute pancreatitis.

Long-term Outcomes following Resection of Adenocarcinoma Arising from Intraductal Papillary Mucinous Neoplasm (A-IPMN) versus Pancreatic Ductal Adenocarcinoma (PDAC): A Propensity-score Matched Analysis

OBJECTIVE

The aim of the present study was to compare long-term post-resection oncological outcomes between A-IPMN and PDAC.

SUMMARY BACKGROUND DATA

Knowledge of long term oncological outcomes (e.g recurrence and survival data) comparing between adenocarcinoma arising from intraductal papillary mucinous neoplasms (A-IPMN) and pancreatic ductal adenocarcinoma (PDAC) is scarce.

METHODS

Patients undergoing pancreatic resection (2010-2020) for A-IPMN were identified retrospectively from 18 academic pancreatic centres and compared with PDAC patients from the same time-period. Propensity-score matching (PSM) was performed and survival and recurrence were compared between A-IPMN and PDAC.

RESULTS

459 A-IPMN patients (median age,70; M:F,250:209) were compared with 476 PDAC patients (median age,69; M:F,262:214). A-IPMN patients had lower T-stage, lymphovascular invasion (51.4%vs. 75.6%), perineural invasion (55.8%vs. 71.2%), lymph node positivity (47.3vs. 72.3%) and R1 resection (38.6%vs. 56.3%) compared to PDAC(P<0.001). The median survival and time-to-recurrence for A-IPMN versus PDAC were 39.0 versus19.5months (P<0.001) and 33.1 versus 14.8months (P<0.001), respectively (median follow-up,78 vs.73 months). Ten-year overall survival for A-IPMN was 34.6%(27/78) and PDAC was 9%(6/67). A-IPMN had higher rates of peritoneal (23.0 vs. 9.1%, P<0.001) and lung recurrence (27.8% vs. 15.6%, P<0.001) but lower rates of locoregional recurrence (39.7% vs. 57.8%; P<0.001). Matched analysis demonstrated inferior overall survival (P=0.005), inferior disease-free survival (P=0.003) and higher locoregional recurrence (P<0.001) in PDAC compared to A-IPMN but no significant difference in systemic recurrence rates (P=0.695).

CONCLUSIONS

PDACs have inferior survival and higher recurrence rates compared to A-IPMN in matched cohorts. Locoregional recurrence is higher in PDAC but systemic recurrence rates are comparable and constituted by their own distinctive site-specific recurrence patterns.

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

OBJECTIVE

To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery.

BACKGROUND

The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain.

METHODS

We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty.

RESULTS

After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer.

CONCLUSIONS

VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

The role of intraoperative pancreatoscopy in the surgical management of intraductal papillary mucinous neoplasms of the pancreas: a systematic scoping review

BACKGROUND

The type and the extent of surgery is still debatable for intraductal papillary mucinous neoplasm (IPMN). Intraoperative pancreatoscopy (IOP) allows the visualization of the main pancreatic duct (MPD) in its entire length and could help determine the extent of MPD involvement and the type and extent of pancreatic resection. However, current guidelines do not advise its routine use as there is a lack of evidence supporting its safety and feasibility. The present study aims to perform a scoping review of published evidence on the safety and feasibility of IOP in IPMN surgical management.

METHODS

We systematically searched PubMed, Cochrane, Medline and EMbase to identify studies reporting the use of IOP in IPMN surgical management. The research was completed in June 2023. Data extracted included patient selection criteria, demographics, safety of the procedure, intraoperative findings, impact on surgical strategy, histology results and postoperative outcomes.

RESULTS

Four retrospective and one prospective study were included in this scoping review. A total of 142 patients had IOP. The selection criteria for inclusion were heterogenous, with one out of five studies including branch duct (BD), main duct (MD) and mixed type IPMN. Indications for IOP and surgical resection were only reported in two studies. A median of seven outcomes (range 5-8) was described, including the type of surgical resection, additional lesions and change of surgical plan, and complications after IOP. IOP showed additional lesions in 48 patients (34%) and a change of surgical plan in 48(34%). No IOP-related complications were reported.

CONCLUSIONS

This scoping review suggests IOP is safe and identifies additional lesions impacting the surgical strategy for IPMN. However, the included studies were small and heterogeneous regarding IPMN definition and indications for surgery and IOP. There is a need for a large multi-centre prospective study to determine the role of IOP and its impact on surgical strategy for IPMN.

Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta-analysis with pre and post-test probability assessment

BACKGROUND

Scoring systems for severe acute pancreatitis (SAP) prediction should be used in conjunction with pre-test probability to establish post-test probability of SAP, but data of this kind are lacking.

OBJECTIVE

To investigate the predictive value of commonly employed scoring systems and their usefulness in modifying the pre-test probability of SAP.

METHODS

Following PRISMA statement and MOOSE checklists after PROSPERO registration, PubMed was searched from inception until September 2022. Retrospective, prospective, cross-sectional studies or clinical trials on patients with acute pancreatitis defined as Revised Atlanta Criteria, reporting rate of SAP and using at least one score among Bedside Index for Severity in Acute Pancreatitis (BISAP), Acute Physiology and Chronic Health Examination (APACHE)-II, RANSON, and Systemic Inflammatory Response Syndrome (SIRS) with their sensitivity and specificity were included. Random effects model meta-analyses were performed. Pre-test probability and likelihood ratio (LR) were combined to estimate post-test probability on Fagan nomograms. Pooled severity rate was used as pre-test probability of SAP and pooled sensitivity and specificity to calculate LR and generate post-test probability. A priori hypotheses for heterogeneity were developed and sensitivity analyses planned.

RESULTS

43 studies yielding 14,116 acute pancreatitis patients were included: 42 with BISAP, 30 with APACHE-II, 27 with Ranson, 8 with SIRS. Pooled pre-test probability of SAP ranged 16.6%-25.3%. The post-test probability of SAP with positive/negative score was 47%/6% for BISAP, 43%/5% for APACHE-II, 48%/5% for Ranson, 40%/12% for SIRS. In 18 studies comparing BISAP, APACHE-II, and Ranson in 6740 patients with pooled pre-test probability of SAP of 18.7%, post-test probability when scores were positive was 48% for BISAP, 46% for APACHE-II, 50% for Ranson. When scores were negative, post-test probability dropped to 7% for BISAP, 6% for Ranson, 5% for APACHE-II. Quality, design, and country of origin of the studies did not explain the observed high heterogeneity.

CONCLUSIONS

The most commonly used scoring systems to predict SAP perform poorly and do not aid in decision-making.

Sarcopenia and Sarcopenic Obesity on Body Composition Analysis is a Significant Predictor of Mortality in Severe Acute Pancreatitis: A Longitudinal Observational Study

BACKGROUND

The prevalence and impact of sarcopenia and sarcopenic obesity noted on body composition analysis in severe acute pancreatitis (SAP) is unknown. This study investigates the prevalence of sarcopenia at different timepoints and its effect on post-pancreatitis complications and mortality.

METHODS

A prospective database of SAP admissions with organ failure at a single institution from 2015 to 2019 were analysed. Sarcopenia was determined by IMAGE J software on CT. Database was further queried for post-pancreatitis complications and mortality.

RESULTS

141 patients with a median age of 59 (range 18-88) and M:F ratio 1.52:1 of were analysed. Sarcopenia was present in 111/141 (79%) patients at admission, 78/79 (99%) at 3 months and 26/36 (72%) at 12 months. 67/111 patients with sarcopenia on admission had sarcopenic obesity. The mortality at 30 days, 3 months and 12 months was 16/141 (11%), 30/141 (21%) and 42/141 (30%) respectively. Mortality was significantly higher in sarcopenic patients at admission (35.14%) compared to the non-sarcopenic group (10%), P = 0.008). Mortality in the sarcopenic obesity group was significantly higher (45%) compared to the sarcopenic non-obese group (20%), P = 0.009) at admission. Multivariate logistic regression identified sarcopenic obesity (OR: 2.880), age (OR: 1.048) and number of organ failures (OR: 3.225) as significant predictors of mortality.

CONCLUSIONS

Sarcopenia and Sarcopenic obesity are highly prevalent in SAP patients on admission and during follow up. Furthermore, sarcopenic obesity was shown to be a significant predictor of mortality at admission, suggesting that body composition analysis could be a potential predictive marker of mortality in SAP patients.

Risk of Recurrence after Surgical Resection for Adenocarcinoma Arising from Intraductal Papillary Mucinous Neoplasia (IPMN) with Patterns of Distribution and Treatment: An International, Multicentre, Observational Study

OBJECTIVE

This international multicentre cohort study aims to identify recurrence patterns and treatment of first and second recurrence in a large cohort of patients after pancreatic resection for adenocarcinoma arising from IPMN.

SUMMARY BACKGROUND DATA

Recurrence patterns and treatment of recurrence post resection of adenocarcinoma arising from IPMN are poorly explored.

METHOD

Patients undergoing pancreatic resection for adenocarcinoma from IPMN between January 2010 to December 2020 at 18 pancreatic centres were identified. Survival analysis was performed by the Kaplan-Meier log rank test and multivariable logistic regression by Cox-Proportional Hazards modelling. Endpoints were recurrence (time-to, location, and pattern of recurrence) and survival (overall survival and adjusted for treatment provided).

RESULTS

Four hundred and fifty-nine patients were included (median, 70 y; IQR, 64-76; male, 54 percent) with a median follow-up of 26.3 months (IQR, 13.0-48.1 mo). Recurrence occurred in 209 patients (45.5 percent; median time to recurrence, 32.8 months, early recurrence [within 1 y], 23.2 percent). Eighty-three (18.1 percent) patients experienced a local regional recurrence and 164 (35.7 percent) patients experienced distant recurrence. Adjuvant chemotherapy was not associated with reduction in recurrence (HR 1.09;P=0.669) One hundred and twenty patients with recurrence received further treatment. The median survival with and without additional treatment was 27.0 and 14.6 months (P<0.001), with no significant difference between treatment modalities. There was no significant difference in survival between location of recurrence (P=0.401).

CONCLUSION

Recurrence after pancreatic resection for adenocarcinoma arising from IPMN is frequent with a quarter of patients recurring within 12 months. Treatment of recurrence is associated with improved overall survival and should be considered.

Machine perfusion in liver transplantation

BACKGROUND

Liver transplantation is the only chance of cure for people with end-stage liver disease and some people with advanced liver cancers or acute liver failure. The increasing prevalence of these conditions drives demand and necessitates the increasing use of donated livers which have traditionally been considered suboptimal. Several novel machine perfusion preservation technologies have been developed, which attempt to ameliorate some of the deleterious effects of ischaemia reperfusion injury. Machine perfusion technology aims to improve organ quality, thereby improving outcomes in recipients of suboptimal livers when compared to traditional static cold storage (SCS; ice box).

OBJECTIVES

To evaluate the effects of different methods of machine perfusion (including hypothermic oxygenated machine perfusion (HOPE), normothermic machine perfusion (NMP), controlled oxygenated rewarming, and normothermic regional perfusion) versus each other or versus static cold storage (SCS) in people undergoing liver transplantation.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 10 January 2023.

SELECTION CRITERIA

We included randomised clinical trials which compared different methods of machine perfusion, either with each other or with SCS. Studies comparing HOPE via both hepatic artery and portal vein, or via portal vein only, were grouped. The protocol detailed that we also planned to include quasi-randomised studies to assess treatment harms.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. overall participant survival, 2. quality of life, and 3. serious adverse events. Secondary outcomes were 4. graft survival, 5. ischaemic biliary complications, 6. primary non-function of the graft, 7. early allograft function, 8. non-serious adverse events, 9. transplant utilisation, and 10. transaminase release during the first week post-transplant. We assessed bias using Cochrane's RoB 2 tool and used GRADE to assess certainty of evidence.

MAIN RESULTS

We included seven randomised trials (1024 transplant recipients from 1301 randomised/included livers). All trials were parallel two-group trials; four compared HOPE versus SCS, and three compared NMP versus SCS. No trials used normothermic regional perfusion. When compared with SCS, it was uncertain whether overall participant survival was improved with either HOPE (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.42 to 1.98; P = 0.81, I2 = 0%; 4 trials, 482 recipients; low-certainty evidence due to imprecision because of low number of events) or NMP (HR 1.08, 95% CI 0.31 to 3.80; P = 0.90; 1 trial, 222 recipients; very low-certainty evidence due to imprecision and risk of bias). No trials reported quality of life. When compared with SCS alone, HOPE was associated with improvement in the following clinically relevant outcomes: graft survival (HR 0.45, 95% CI 0.23 to 0.87; P = 0.02, I2 = 0%; 4 trials, 482 recipients; high-certainty evidence), serious adverse events in extended criteria DBD liver transplants (OR 0.45, 95% CI 0.22 to 0.91; P = 0.03, I2 = 0%; 2 trials, 156 participants; moderate-certainty evidence) and clinically significant ischaemic cholangiopathy in recipients of DCD livers (OR 0.31, 95% CI 0.11 to 0.92; P = 0.03; 1 trial, 156 recipients; high-certainty evidence). In contrast, NMP was not associated with improvement in any of these clinically relevant outcomes. NMP was associated with improved utilisation compared with SCS (one trial found a 50% lower rate of organ discard; P = 0.008), but the reasons underlying this effect are unknown. We identified 11 ongoing studies investigating machine perfusion technologies.

AUTHORS' CONCLUSIONS

In situations where the decision has been made to transplant a liver donated after circulatory death or donated following brain death, end-ischaemic HOPE will provide superior clinically relevant outcomes compared with SCS alone. Specifically, graft survival is improved (high-certainty evidence), serious adverse events are reduced (moderate-certainty evidence), and in donors after circulatory death, clinically relevant ischaemic biliary complications are reduced (high-certainty evidence). There is no good evidence that NMP has the same benefits over SCS in terms of these clinically relevant outcomes. NMP does appear to improve utilisation of grafts that would otherwise be discarded with SCS; however, the reasons for this, and whether this effect is specific to NMP, is not clear. Further studies into NMP viability criteria and utilisation, as well as head-to-head trials with other perfusion technologies are needed. In the setting of donation following circulatory death transplantation, further trials are needed to assess the effect of these ex situ machine perfusion methods against, or in combination with, normothermic regional perfusion.

The development of new onset post-pancreatitis diabetes mellitus during hospitalisation is not associated with adverse outcomes

BACKGROUND

Patients with acute pancreatitis (AP) are at increased risk of developing post pancreatitis diabetes mellitus (PPDM). The aim of this study was to explore the incidence, risk factors and sequelae of developing PPDM in a UK tertiary referral centre.

METHODS

A prospectively collected single centre database was analysed. Patients were grouped according to whether they had DM or not. Patients with DM were further sub-grouped into pre-existing DM or PPDM. Outcomes measured included incidence of PPDM, mortality, ITU admission, overall length of stay (LOS) and local pancreatitis specific complications.

RESULTS

401 patients with AP between 2018 and 2021 were identified. Sixty-four (16%) of patients had pre-existing DM. Thirty-eight patients (11%) developed PPDM [mild (n = 4, 8.2%), moderate (n = 19, 10.1%), severe (n = 15, 15.2%), p = 0.326]. 71% required insulin therapy for the duration of follow-up or until death. The development of PPDM was strongly associated with the presence (p < 0.001) and extent of necrosis (p < 0.0001). On multi-variate analysis, the development of PPDM was not an independent predictor for increased LOS, ITU admission or overall mortality.

CONCLUSIONS

The incidence of PPDM was 11%. There was a strong correlation with extent of necrosis and the development of PPDM. PPDM did not adversely affect morbidity or mortality.

Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review

BACKGROUND

Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest.

AIM

To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF.

METHODS

A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications.

RESULTS

Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified.

CONCLUSION

The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.

Systematic review and meta-analysis of cost-effectiveness of minimally invasive versus open pancreatic resections

BACKGROUND

The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy.

METHOD

The MEDLINE, CENTRAL, EMBASE, Centre for Reviews and Dissemination, and clinical trial registries were systematically searched using the PRISMA framework. Studies of adults aged ≥ 18 year comparing laparoscopic and/or robotic versus open DP and/or PD that reported cost of operation or index admission, and cost-effectiveness outcomes were included. The risk of bias of non-randomised studies was assessed using the Newcastle-Ottawa Scale, while the Cochrane Risk of Bias 2 (RoB2) tool was used for randomised studies. Standardised mean differences (SMDs) with 95% confidence intervals (CI) were calculated for continuous variables.

RESULTS

Twenty-two studies (152,651 patients) were included in the systematic review and 15 studies in the meta-analysis (3 RCTs; 3 case-controlled; 9 retrospective studies). Of these, 1845 patients underwent MIS (1686 laparoscopic and 159 robotic) and 150,806 patients open surgery. The cost of surgical procedure (SMD 0.89; 95% CI 0.35 to 1.43; I2 = 91%; P = 0.001), equipment (SMD 3.73; 95% CI 1.55 to 5.91; I2 = 98%; P = 0.0008), and operating room occupation (SMD 1.17, 95% CI 0.11 to 2.24; I2 = 95%; P = 0.03) was higher with MIS. However, overall index hospitalisation costs trended lower with MIS (SMD - 0.13; 95% CI - 0.35 to 0.06; I2 = 80%; P = 0.17). There was significant heterogeneity among the studies.

CONCLUSION

Minimally invasive major pancreatic surgery entailed higher intraoperative but similar overall index hospitalisation costs.

Assessing impact, needs and quality-of-life among informal carers of people with pancreatic cancer, a prospective study: the PAN-CARER study protocol

INTRODUCTION

Approximately 10 300 people are diagnosed with pancreatic cancer each year in the UK. The cancer and its treatment inflict a significant physical, functional and emotional burden on patients. Research suggests that patients have many ongoing needs for support and care, but that these needs are not met by existing services. Family members often step in to fill this gap and provide support and care during and after treatment. Research in other cancers shows that this informal caregiving can place a very heavy burden on carers. However, there are few studies in the international literature that have focused on informal carers in pancreatic cancer; none have been conducted in the UK.

METHODS AND ANALYSIS

Two complementary research methods will be utilised. First, a longitudinal quantitative study of 300 carers investigating, using validated questionnaires to assess the impact of caregiving (Caregiver Reaction Assessment), the unmet needs of carers (Supportive Care Needs Survey) and the quality-of-life (Short Form 12-item health survey), will be conducted. Second, qualitative interviews will be conducted with up to 30 carers to explore their experiences in more depth. Mixed-effects regression models will be applied to survey results to determine how impact, needs and quality-of-life vary over time, compare outcomes between carers of patients with operable and inoperable disease and identify social factors which affect outcomes. Interview data will undergo reflexive thematic analysis.

ETHICS AND DISSEMINATION

The protocol has been approved by the Health Research Authority of the UK (Ethical approval IRAS ID 309503). Findings will be published in peer-reviewed journals and presented at national and international conferences.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Irreversible Electroporation for Liver Metastases from Colorectal Cancer: A Systematic Review

BACKGROUND

Irreversible electroporation (IRE) is a non-thermal form of ablation based on the delivery of pulsed electrical fields. It has been used to treat liver lesions, particularly those in proximity to major hepatic vasculature. The role of this technique in the portfolio of treatments for colorectal hepatic metastases has not been clearly defined. This study undertakes a systematic review of IRE for treatment of colorectal hepatic metastases.

METHODS

The study protocol was registered with the PROSPERO register of systematic reviews (CRD42022332866) and reports in compliance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The Ovid MEDLINE^®, EMBASE, Web of Science and Cochrane databases were queried in April 2022. The search terms 'irreversible electroporation', 'colon cancer', 'rectum cancer' and 'liver metastases' were used in combinations. Studies were included if they provided information on the use of IRE for patients with colorectal hepatic metastases and reported procedure and disease-specific outcomes. The searches returned 647 unique articles and the exclusions left a total of eight articles. These were assessed for bias using the methodological index for nonrandomized studies (MINORS criteria) and reported using the synthesis without meta-analysis guideline (SWiM).

RESULTS

One hundred eighty patients underwent treatment for liver metastases from colorectal cancer. The median transverse diameter of tumours treated by IRE was <3 cm. Ninety-four (52%) tumours were adjacent to major hepatic inflow/outflow structures or the vena cava. IRE was undertaken under general anaesthesia with cardiac cycle synchronisation and with the use of either CT or ultrasound for lesion localisation. Probe spacing was less than 3.2 cm for all ablations. There were two (1.1%) procedure-related deaths in 180 patients. There was one (0.5%) post-operative haemorrhage requiring laparotomy, one (0.5%) bile leak, five (2.8%) post-procedure biliary strictures and a zero incidence of post-IRE liver failure.

CONCLUSIONS

This systematic review shows that IRE for colorectal liver metastases can be accomplished with low procedure-related morbidity and mortality. Further prospective study is required to assess the role of IRE in the portfolio of treatments for patients with liver metastases from colorectal cancer.

Position statement on the definition, incidence, diagnosis and outcome of acute on chronic pancreatitis

BACKGROUND

Acute on chronic pancreatitis (ACP) is a relatively common condition, but there are significant gaps in our knowledge on the definition, incidence, diagnosis, treatment and prognosis.

METHODS

A systematic review that followed PICO (Population; Intervention; Comparator; Outcome) recommendation for quantitative questions and PICo (Population, Phenomenon of Interest, Context) for qualitative research was done to answer 10 of the most relevant questions about ACP. Quality of evidence was judged by the GRADE criteria (Grades of Recommendation, Assessment, Development and Evaluation). The manuscript was sent for review to 12 international experts from various disciplines and continents using a Delphi process.

RESULTS

The quality of evidence, for most statements, was low to very low, which means that the recommendations in general are only conditional. Despite that, it was possible to reach strong levels of agreement by the expert panel for all 10 questions. A new consensus definition of ACP was reached. Although common, the real incidence of ACP is not known, with alcohol as a major risk factor. Although pain dominates, other non-specific symptoms and signs can be present. Serum levels of pancreatic enzymes may be less than 3 times the upper limit of normal and cross-sectional imaging is considered more accurate for the diagnosis in many cases. It appears that it is less severe and with a lower mortality risk than acute pancreatitis.

CONCLUSIONS

Although the evidence base is poor, this position statement provides a foundation from which to advance management of ACP.

Social deprivation does not impact on acute pancreatitis severity and mortality: a single-centre study

BACKGROUND AND AIMS

The incidence of acute pancreatitis (AP) is increasing in the UK. Patients with severe AP require a significant amount of resources to support them during their admission. The ability to predict which patients will develop multiorgan dysfunction remains poor leading to a delay in the identification of these patients and a window of opportunity for early intervention is missed. Social deprivation has been linked with increased mortality across surgical specialties. Its role in predicting mortality in patients with AP remains unclear but would allow high-risk patients to be identified early and to focus resources on high-risk populations.

METHODS

A prospectively collected single-centre database was analysed. English Index of Multiple Deprivation (IMD) was calculated based on postcode. Patients were grouped according to their English IMD quintile. Outcomes measured included all-cause mortality, Intestive care unit (ITU) admission, overall length of stay (LOS) and local pancreatitis-specific complications.

RESULTS

398 patients with AP between 2018 and 2021 were identified. There were significantly more patients with AP in Q1 (IMD 1-2) compared with Q5 (IMD 9-10) (156 vs 38, p<0.001). Patients who were resident in the most deprived areas were significantly younger (52.4 in Q1 vs 65.2 in Q5, p<0.001), and more often smokers (39.1% in Q1 vs 23.7% in Q5, p=0.044) with IHD (95.0% vs 92.1% in Q5, p<0.001). In multivariate modelling, there was no significance difference in pancreatitis-related complications, number of ITU visits, number of organs supported and overall, LOS by IMD quintile.

CONCLUSIONS

Although there was a significantly higher number of patients admitted to our unit with AP from the most socially deprived quintiles, there was no correlation between social economic deprivation and mortality following AP.

The safety and efficacy of epidural anaesthesia in acute pancreatitis: a systematic review and meta-analysis

BACKGROUND

Acute pancreatitis (AP) has variable clinical courses. This systematic review and meta-analysis aimed to determine the safety, efficacy, and impact of epidural anaesthesia (EA) use in AP.

METHODS

The PubMed, EMBASE, SCOPUS and Cochrane library databases were systematically searched between 1980 and 2022 using the PRISMA guidelines, to identify observational and comparative studies reporting on EA in AP. The meta-analysis was performed in R Foundation for Statistical Computing using the meta R Package for Meta-Analysis.

RESULTS

A total of 9 studies with 2006 patients of which 726 (36%) patients had EA were included. All studies demonstrated high safety and feasibility of EA in AP with no reported major local or neurological complications. One randomised controlled trial demonstrated an improvement in pain severity using a 0-10 visual analogue scale (VAS) at the outset (1.6 in EA vs 3.5 in non-EA, P = 0.02) and on day 10 (0.2 in EA vs 2.33 in non-EA, P = 0.034). There was also improvement in pancreatic perfusion with EA measured with computerised tomography 13 (43%) in EA vs 2 (7%) in non-EA, P = 0.003. The need for ventilatory support and overall mortality was lower in EA patients 40 (19%) vs 285 (24%) P = 0.025 (OR: 0.49, 95% CI: 0.28-0.84) and 16 (7%) vs 214 (20%), P = 0.050 (OR: 0.39, 95% CI: 0.15-1.00), respectively.

CONCLUSION

EA is infrequently used for pain management in AP and yet the available evidence suggests that it is safe and effective in reducing pain severity, improving pancreatic perfusion, and decreasing mortality.

Delayed Gastric Emptying and Gastric Remnant Function After Pancreaticoduodenectomy: A Systematic Review of Objective Assessment Modalities

BACKGROUND

Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD). The diagnosis of DGE is based on International Study Group for Pancreatic Surgery (ISGPS) clinical criteria and objective assessments of DGE are infrequently used. The present literature review aimed to identify objective measures of DGE following PD and determine whether these measures correlate with the clinical definition of DGE.

METHODS

A systematic search was performed using the MEDLINE Ovid, EMBASE, Google Scholar and CINAHL databases for studies including pancreatic surgery, delayed gastric emptying and gastric motility until June 2022. The primary outcome was modalities undertaken for the objective measurement of DGE following PD and correlation between objective measurements and clinical diagnosis of DGE. Relevant risk of bias analysis was performed.

RESULTS

The search revealed 4881 records, of which 46 studies were included in the final analysis. There were four objective modalities of DGE assessment including gastric scintigraphy (n = 28), acetaminophen/paracetamol absorption test (n = 10), fluoroscopy (n = 6) and the ¹³C-acetate breath test (n = 3). Protocols were inconsistent, and reported correlations between clinical and objective measures of DGE were variable; however, amongst these measures, at least one study directly or indirectly inferred a correlation, with the greatest evidence accumulated for gastric scintigraphy.

CONCLUSION

Several objective modalities to assess DGE following PD have been identified and evaluated, however are infrequently used. Substantial variability exists in the literature regarding indications and interpretation of these tests, and there is a need for a real-time objective modality which correlates with ISGPS DGE definition after PD.

Systematic review of caregiver burden, unmet needs and quality-of-life among informal caregivers of patients with pancreatic cancer

PURPOSE

Informal caregivers play an important supportive care role for patients with cancer. This may be especially true for pancreatic cancer which is often diagnosed late, has a poor prognosis and is associated with a significant symptom burden. We systematically reviewed the evidence on caregiver burden, unmet needs and quality-of-life of informal caregivers to patients with pancreatic cancer.

METHOD

PubMed, Medline, CINAHL and Embase databases were systematically searched on 31 August 2021. Qualitative and quantitative data on informal caregivers' experiences were extracted and coded into themes of burden, unmet needs or quality-of-life with narrative synthesis of the data undertaken.

RESULTS

Nine studies (five qualitative, four quantitative), including 6023 informal caregivers, were included in the review. We categorised data into three key themes: caregiver burden, unmet needs and quality-of-life. Data on caregiver burden was organised into a single subtheme relating to symptom management as a source of burden. Data on unmet needs was organised into three subthemes need for: better clinical communication; support and briefings for caregivers; and help with navigating the health care system. Data on quality-of-life indicate large proportions of informal caregivers experience clinical levels of anxiety (33%) or depression (12%-32%). All five qualitative studies were graded as good quality; three quantitative studies were poor quality, and one was fair quality.

CONCLUSION

High-quality pancreatic cancer care should consider the impacts of informal caregiving. Prospective longitudinal studies examining multiple dimensions of caregiver burden, needs, and quality-of-life would be valuable at informing supportive care cancer delivery to pancreatic cancer informal caregivers.

HPB P27 Stereotactic Ablative Radiotherapy in Colorectal Liver Metastases: A Systematic Review and Descriptive Summary of Practice

Background

Treatment options for unresectable Colorectal Liver Metastases (CRLM) have, until recently, been mostly limited to radiofrequency or microwave ablation though there are some limitations. Stereotactic Ablative Radiotherapy (SABR) is being used increasingly to overcome these limitations with control rates and survival outcomes, reported to be comparable to ablation. However, there are several unknown factors regarding the use of SABR in CRLM, including the criteria for patient selection, optimal dose delivery and target volumes. This systematic review aims to summarise and describe the patient selection, indications, treatment regimens and survival outcomes for SABR in CRLM.

Methods

The literature was searched systematically to identify all articles reporting on SABR for CRLM, from inception until 1st January 2021. Primary research studies were included if they described the patient inclusion criteria, treatment regimens and outcomes from inoperable CRLM. Studies with extra-hepatic colorectal metastases were included if the metastases were deemed treatable with local therapies. Recommendations from the UK SABR consortium was used to categorise radiation dosage and fractionation. Data were collected on patient demographics, selection criteria, radiotherapy delivery and dosage and survival outcomes.

Results

Fifteen studies were included with a total of 522 patients and 770 liver metastases.

Most studies (9/15) included patients with three or fewer metastases, however the tumour size varied from 4–15cm. Eleven studies stipulated that CRLM must be unresectable, with only one study defining unresectability according to patient or disease characteristics. Three quoted inoperability after multidisciplinary or tumour board decision, the remainder did not justify inoperability. Of these eleven, six studies stipulated that they must also be unsuitable for ablation. Patients with extra-hepatic metastases were included in ten studies, but the justification was inconsistent across all studies.

Total radiation dose and fractionation varied across all studies, ranging from 16–75Gy and 3–8 fractions respectively. No studies pre-determined a target dosage for any cohort. Approximately half (149/301) of all patients received regimens in accordance with the UK SABR Consortium recommendations. Immobilisation methods were reported in eleven studies with nine different permutations including moulds, frames, abdominal compressions or breath control techniques.

One year local control was reported at 48–96%, 2 years: 36–91% and 3 years: 26–85%. Overall survival at 1 year ranged from 53–100%, 2 years: 26–81% and 3 years: 21–65%.

Conclusions

There are significant variations in practice for delivering SABR for CRLM. There is no absolute consensus determining patient selection or treatment regimens. Although outcomes may seem promising in a selection of studies, the wide range of results and heterogeneity of studies means that truly reliable conclusions cannot be synthesised. Consensus statements to inform high-quality prospective studies are urgently needed to optimise treatment and improve patient outcomes.

Body surface gastric mapping to determine gastric motility patterns associated with delayed gastric emptying after pancreaticoduodenectomy. Gastric Electric Mapping after Pancreatoduodenectomy study protocol

INTRODUCTION

Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Although often associated with postoperative pancreatic fistula, the precise pathogenesis in patients with no underlying complications remains unclear. There is evidence to suggest that, after surgery, aberrant electrical pathways are formed in the stomach which could contribute to the development of DGE.Gastric Alimetry is a novel technology which measures the electrical activity of the stomach non-invasively using an array of electrodes applied to the skin of the abdomen. This technique, termed body surface gastric mapping (BSGM), has been validated in normal controls and in patients with functional dyspepsia syndromes. This study will investigate the efficacy and feasibility of using BSGM to assess gastric motility in patients who undergo PD.

METHODS AND ANALYSIS

This prospective cohort study will be conducted at a single large volume hepatobiliary unit in the UK. 50 patients who are planned to undergo PD will be included. BSGM measurement will be performed at four timepoints viz: preoperatively, day 4 postoperatively, at discharge and 6 months postoperatively. Key parameters of BSGM measurement, including wave amplitude, frequency and directional vector, will be measured at each timepoint and compared between different patient subgroups. Symptoms will be self-reported by patients during the recording using an iPad application designed for this purpose. Quality of life and patient experience will be assessed using standardised questionnaires at the end of the follow-up period.

ETHICS AND DISSEMINATION

The protocol has been approved by the research ethics committees of Newcastle University and the Health Research Authority (HRA) of the UK (ethical approval IRAS ID 305302). Findings will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

This study will automatically be registered with the ISRCTN registry by the HRA as part of the ethics approval process.

Portal vein embolization versus dual vein embolization for management of the future liver remnant in patients undergoing major hepatectomy: meta-analysis

Background

This meta-analysis aimed to compare progression to surgery, extent of liver hypertrophy, and postoperative outcomes in patients planned for major hepatectomy following either portal vein embolization (PVE) or dual vein embolization (DVE) for management of an inadequate future liver remnant (FLR).

Methods

An electronic search was performed of MEDLINE, Embase, and PubMed databases using both medical subject headings (MeSH) and truncated word searches. Articles comparing PVE with DVE up to January 2022 were included. Articles comparing sequential DVE were excluded. ORs, risk ratios, and mean difference (MD) were calculated using fixed and random-effects models for meta-analysis.

Results

Eight retrospective studies including 523 patients were included in the study. Baseline characteristics between the groups, specifically, age, sex, BMI, indication for resection, and baseline FLR (ml and per cent) were comparable. The percentage increase in hypertrophy was larger in the DVE group, 66 per cent in the DVE group versus 27 per cent in the PVE group, MD 39.07 (9.09, 69.05) (P = 0.010). Significantly fewer patients failed to progress to surgery in the DVE group than the PVE group, 13 per cent versus 25 per cent respectively OR 0.53 (0.31, 0.90) (P = 0.020). Rates of post-hepatectomy liver failure 13 per cent versus 22 per cent (P = 0.130) and major complications 20 per cent versus 28 per cent (Clavien–Dindo more than IIIa) (P = 0.280) were lower. Perioperative mortality was lower with DVE, 1 per cent versus 10 per cent (P = 0.010)

Conclusion

DVE seems to produce a greater degree of hypertrophy of the FLR than PVE alone which translates into more patients progressing to surgery. Higher quality studies are needed to confirm these results.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

PURPOSE

A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort.

METHODS

An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included.

RESULTS

A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%.

CONCLUSION

Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.

Management of Splanchnic Vein Thrombosis in Patients With Acute Pancreatitis: An International Survey of Current Practice

OBJECTIVES

Splanchnic venous thrombosis (SpVT) is a complication of acute pancreatitis (AP). There is scarce literature on the prevalence and treatment of SpVT in AP. The aim of this international survey was to document current approaches to the management of SpVT in patients with AP.

METHODS

An online survey was designed by a group of international experts in the management of AP. Twenty-eight questions covered the level of experience of the respondents, disease demographics, and management of SpVT.

RESULTS

There were 224 respondents from 25 countries. Most respondents (92.4%, n = 207) were from tertiary hospitals and predominantly consultants (attendings, 86.6%, n = 194). More than half of the respondents (57.2%, n = 106) "routinely" prescribed prophylactic anticoagulation for AP. Less than half of the respondents (44.3%, n = 82) "routinely" prescribed therapeutic anticoagulation for SpVT. A clinical trial was considered justified by most respondents (85.4%, n = 157) and 73.2% (n = 134) would be willing to enroll their patients.

CONCLUSIONS

The approach to anticoagulation in the treatment of patients with SpVT complicating AP was highly variable. Respondents indicate that a position of equipoise exists to justify randomized evaluation.

Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS).

METHODS

A systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN).

RESULTS

Four studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44-1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31-2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference -3.40 days; 95% -6.11-0.70 days; p = 0.01).

CONCLUSION

Current available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.

Are older patients less likely to be treated for pancreatic cancer? A systematic review and meta-analysis

Pancreatic cancer is the seventh commonest cause of cancer-related death worldwide. Although prognosis is poor, both surgery and adjuvant chemotherapy improve survival. However, it has been suggested that not all pancreatic cancer patients who may benefit from treatment receive it. This systematic review and meta-analysis investigated the existence of age-related inequalities in receipt of first-line pancreatic cancer treatment. Medline, Embase, Cochrane Library and grey literature were searched for population-based studies investigating treatment receipt, reported by age, for patients with primary pancreatic cancer from inception until 4th June 2020, and updated 5th August 2021. Studies from countries with universal healthcare were included, to minimise influence of health system-related economic factors. A modified version of the Newcastle-Ottawa Scale was used to assess risk of bias. Random-effects meta-analysis was undertaken comparing likelihood of treatment receipt in older versus younger patients. Sensitivity and subgroup analyses were conducted. Eighteen papers were included; 12 independent populations were eligible for meta-analysis. In most studies, < 10% of older patients were treated. Older age (generally ≥65) was significantly associated with reduced receipt of any treatment (OR=0.14, 95% CI 0.10-0.21, n = 12 studies), surgery (OR=0.15, 95% CI 0.09-0.24, n = 9 studies) and chemotherapy as a primary treatment (OR=0.13, 95% CI 0.07-0.24, n = 5 studies). The effect of age was independent of methodological quality, patient population or time-period of patient diagnosis and remained in studies with confounder adjustment. The mean quality score of included studies was 6/8. Inequalities in receipt of healthcare interventions across social groups is a recognised concern internationally. This review shows that older age is significantly, and consistently, associated with non-receipt of treatment in pancreatic cancer. However, there are risks and side-effects associated with pancreatic cancer treatment. Further research on what influences patient and professional treatment decision-making is required to better understand these apparent inequalities.

O001 SARS-CoV-2 pandemic has impacted on patterns of aetiology for acute pancreatitis and management of gallstone pancreatitis in the United Kingdom

Introduction

The impact of the SARS-CoV-2 pandemic on patterns of aetiology of acute pancreatitis (AP) and management of AP in the UK is unknown.

Methods

A prospective multicentre cohort study of consecutive patients admitted with AP between 01/03/2020 and 23/07/2020 was undertaken. Patients were followed up for 12 months.

Results

1628 patients presenting with AP were included in the analysis. Gallstones (GSP) were the predominant aetiology (43.6%), followed by alcohol associated (25.8) and idiopathic (21.5%) AP. After completing aetiological investigations, 14.4% of the idiopathic cohort remained to have an idiopathic aetiology. 113/187 patients were readmitted during the ‘second wave’ of SARS-CoV-2 pandemic (after September 2020) with predominantly alcohol-related AP aetiology (49, 43.3%). Patients readmitted during the ‘second wave’, more commonly had alcoholic AP compared to the index cohort (43.4% vs 23.5% respectively; p<0.001); however, there were no significant differences in AP severity (p=0.268). Of the 1358 patients with complete follow-up data, 620 (45.7%) presented with GSP of which only 66 (10.6%) underwent index cholecystectomy and 108 (17.4%) had an interval cholecystectomy with median waiting time of 32 days (IQR 16–56). Accounting for 44/456 patients with previous cholecystectomies, and 24 patients deemed unfit for cholecystectomy, the remaining 388 (77.3%) were still awaiting cholecystectomy at the end of 12 months.

Conclusion

The patterns of aetiology for AP changed during the SARS-CoV-2 pandemic with an increase in alcohol associated AP. Most significantly, access to cholecystectomy was restricted during the pandemic and readmission to hospital may have been driven by the need for cholecystectomy.

Take-home message

The patterns of aetiology for AP changed during the SARS-CoV-2 pandemic with an increase in alcohol associated AP. Most significantly, access to cholecystectomy was restricted during the pandemic and readmission to hospital may have been driven by the need for cholecystectomy.

Quality of life after surgical and endoscopic management of severe acute pancreatitis: A systematic review

BACKGROUND

Treatment for severe acute severe pancreatitis (SAP) can significantly affect Health-related quality of life (HR-QoL). The effects of different treatment strategies such as endoscopic and surgical necrosectomy on HR-QoL in patients with SAP remain poorly investigated.

AIM

To critically appraise the available evidence on HR-QoL following surgical or endoscopic necrosectomy in patient with SAP.

METHODS

A literature search was performed on PubMed, Google™ Scholar, the Cochrane Library, MEDLINE and Reference Citation Analysis databases for studies that investigated HR-QoL following surgical or endoscopic necrosectomy in patients with SAP. Data collected included patient characteristics, outcomes of interventions and HR-QoL-related details.

RESULTS

Eleven studies were found to have evaluated HR-QoL following treatment for severe acute pancreatitis including 756 patients. Three studies were randomized trials, four were prospective cohort studies and four were retrospective cohort studies with prospective follow-up. Four studies compared HR-QoL following surgical and endoscopic necrosectomy. Several metrics of HR-QoL were used including Short Form (SF)-36 and EuroQol. One randomized trial and one cohort study demonstrated significantly improved physical scores at three months in patients who underwent endoscopic necrosectomy compared to surgical necrosectomy. One prospective study that examined HR-QoL following surgical necrosectomy reported some deterioration in the functional status of the patients. On the other hand, a cohort study that assessed the long-term HR-QoL following sequential surgical necrosectomy stated that all patients had SF-36 > 60%. In the only study that examined patients following endoscopic necrosectomy, the HR-QoL was also very good. Three studies investigated the quality adjusted life years suggesting that endoscopic and surgical approaches to management of pancreatic necrosis were comparable in cost effectiveness. Finally, regarding HR-QoL between open necrosectomy and minimally invasive approaches, patients who underwent the later had a significantly better overall quality of life, vitality and mental health.

CONCLUSION

This review would suggest that the endoscopic approach might offer better HR-QoL compared to surgical necrosectomy. However, the available comparative literature was very limited. More randomized trials powered to detect differences in HR-QoL are required.

Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis

BACKGROUND

Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature.

METHODS

The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection.

RESULTS

There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings.

CONCLUSION

The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.

Systematic review of sarcopenia in chronic pancreatitis: prevalence, impact on surgical outcomes, and survival

INTRODUCTION

Chronic pancreatitis (CP) is characterized 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.

AREAS COVERED

A systematic literature search of MEDLINE (via PUBMED), Cochrane and EMBASE databases was undertaken to identify articles describing body composition assessment in patients with CP. Data collected included definitions of sarcopenia, sarcopenia assessment methodology, baseline demographics, surgical outcomes, and short- and long-term outcomes.

EXPERT OPINION

In total, nine studies reported on 977 patients with a sarcopenia prevalence of 32.3% (95% CI 22.9-42.6%). CT remains the primary modality to assess for sarcopenia, due to ease of access. None of the studies reporting on post-operative outcomes for patients with chronic pancreatitis found a significant increase in complications among those with sarcopenia. Mortality within 1 year in the outpatient setting from one study of patients with CP was 16% in sarcopenic patients versus 3% (HR: 6.69 (95% CI: 1.79-24.9), p < 0.001) in those with no sarcopenia.Sarcopenia is prevalent in patients with CP occurring in approximately a third of patients. Sarcopenia is associated with an adverse impact on long-term survival.

Can trainees safely perform pancreatoenteric anastomosis? A systematic review, meta-analysis, and risk-adjusted analysis of postoperative pancreatic fistula

BACKGROUND

The complexity of pancreaticoduodenectomy and fear of morbidity, particularly postoperative pancreatic fistula, can be a barrier to surgical trainees gaining operative experience. This meta-analysis sought to compare the postoperative pancreatic fistula rate after pancreatoenteric anastomosis by trainees or established surgeons.

METHODS

A systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with differences in postoperative pancreatic fistula rates after pancreatoenteric anastomosis between trainee-led versus consultant/attending surgeons pooled using meta-analysis. Variation in rates of postoperative pancreatic fistula was further explored using risk-adjusted outcomes using published risk scores and cumulative sum control chart analysis in a retrospective cohort.

RESULTS

Across 14 cohorts included in the meta-analysis, trainees tended toward a lower but nonsignificant rate of all postoperative pancreatic fistula (odds ratio: 0.77, P = .45) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.69, P = .37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3 mm (odds ratio: 0.45, P = .05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted all postoperative pancreatic fistula (median: 20 vs 26%, P < .001) and clinically relevant postoperative pancreatic fistula (7 vs 9%, P = .020) rates than consultant/attending surgeons, based on preoperative risk scores. After adjusting for this on multivariable analysis, the risks of all postoperative pancreatic fistula (odds ratio: 1.18, P = .604) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.85, P = .693) remained similar after pancreatoenteric anastomosis by trainees or consultant/attending surgeons.

CONCLUSION

Pancreatoenteric anastomosis, 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.

Systematic review and meta-analysis of survival outcomes in T2a and T2b gallbladder cancers

BACKGROUND

The 8th edition of AJCC TNM staging of Gallbladder cancer subdivided T2 stage into T2a and T2b based on tumour location. This meta-analysis aimed to investigate the long-term outcomes in T2a and T2b gallbladder cancers.

METHODS

Literature search of Medline, Web of science, Embase and Cochrane databases was performed. Study characteristics, survival and recurrence data were extracted for meta-analysis of effect estimates and of individual patient data.

RESULTS

Fifteen retrospective studies (2531 patients, T2a = 1332, T2b = 199) were included in the meta-analysis. Overall survival (OS) was significantly worse in patients with T2b compared to T2a tumours (HR 2.18, 95% CI 1.67-2.86, p < 0.0001). Meta-analysis of individual patient data (n = 629) showed similar results (HR 1.92, 95% CI 1.43-2.58, p < 0.00001). Patients with T2b tumours had higher risk of recurrence compared to T2a (OR 3.19, 95% CI 1.40-7.28, p = 0.006) and were more likely to receive adjuvant chemotherapy (OR 1.76, 95% CI 1.12-2.84, p = 0.014). Liver resection improved OS in T2b tumours (HR 2.99, CI 1.73-5.16, p < 0.0001).

CONCLUSION

T2b gallbladder tumours have worse overall survival and increase risk of recurrence compared to T2a. Liver resection appears to improve OS in patients with T2b tumours. However, high quality multicenter data is required to confirm these results.