Sortase-Modified Cholera Toxoids Show Specific Golgi Localization

Cholera toxoid is an established tool for use in cellular tracing in neuroscience and cell biology. We use a sortase labeling approach to generate site-specific N-terminally modified variants of both the A2-B5 heterohexamer and B5 pentamer forms of the toxoid. Both forms of the toxoid are endocytosed by GM1-positive mammalian cells, and while the heterohexameric toxoid was principally localized in the ER, the B5 pentamer showed an unexpectedly specific localization in the medial/trans-Golgi. This study suggests a future role for specifically labeled cholera toxoids in live-cell imaging beyond their current applications in neuronal tracing and labeling of lipid rafts in fixed cells.

E7-mediated repression of miR-203 promotes LASP1-dependent proliferation in HPV-positive cervical cancer

Human papillomaviruses (HPV) are a major cause of malignancy, contributing to ∼5% of all human cancers worldwide, including most cervical cancer cases and a growing number of ano-genital and oral cancers. The major HPV viral oncogenes, E6 and E7, manipulate many host cellular pathways that promote cell proliferation and survival, predisposing infected cells to malignant transformation. Despite the availability of highly effective vaccines, there are still no specific anti-viral therapies targeting HPV or treatments for HPV-associated cancers. As such, a better understanding of viral-host interactions may allow the identification of novel therapeutic targets. Here, we demonstrate that the actin-binding protein LASP1 is upregulated in cervical cancer and significantly correlates with a poorer overall survival. In HPV positive cervical cancer, LASP1 depletion significantly inhibited proliferation in vitro , whilst having minimal effects in HPV negative cervical cancer cells. Furthermore, we show that the LASP1 SH3 domain is essential for LASP1-mediated proliferation in these cells. Mechanistically, we show that HPV E7 regulates LASP1 at the post-transcriptional level by repressing the expression of miR-203, which negatively regulated LASP1 mRNA levels by binding to its 3'UTR. Finally, we demonstrated that LASP1 expression is required for the growth of HPV positive cervical cancer cells in an in vivo tumourigenicity model. Together, these data demonstrate that HPV induces LASP1 expression to promote proliferation and survival role in cervical cancer, thus identifying a potential therapeutic target in these cancers.

The effect of a 'Sip til Send' policy on patient satisfaction: a quality improvement project

Patients often are nil by mouth for prolonged periods pre-operatively, which is associated with adverse effects including discomfort, anxiety, thirst and nausea. As a result, several hospitals have introduced a more liberal regimen of pre-operative drinking, with patients encouraged to sip small volumes of water until transfer to the operating theatre ('Sip til Send'). The impact of 'Sip til Send' on patient satisfaction is still to be determined. We hypothesised that the introduction of a 'Sip til Send' policy would increase patient's satisfaction with their pre-operative fluid management regimen. We conducted a staged implementation of a 'Sip til Send' quality improvement initiative in two campuses of a large tertiary teaching hospital. This involved a targeted education and implementation programme that was refined and delivered through 'plan, do, study and act' cycles. Patient satisfaction with their pre-operative fluid management was measured by rating the statement "I am happy with the management of pre-operative drinking", against a five-point Likert scale (0, strongly disagree; 1, disagree; 2, neutral; 3, agree; and 4, strongly agree). Patient satisfaction with pre-operative fluid management was high at baseline, with pooled data for both campuses showing a median (IQR [range]) satisfaction score of 4 (3-4 [1-4]). After the implementation of 'Sip til Send', this improved to a median (IQR [range]) satisfaction score of 4 (4-4 [2-4]) (p < 0.001). The introduction of a 'Sip til Send' policy resulted in an increase in patient satisfaction. Key factors in successful implementation included the provision of a clear explanation of the underlying rationale to patients, nursing and anaesthetic staff, and establishing the policy as the default position for all elective patients.

An unexpected case of broncholithiasis secondary to pulmonary nocardiosis

Persistent productive cough despite appropriate treatment warrants consideration of flexible bronchoscopy to obtain bronchial specimens for culture. Endobronchial examination of airways may reveal signs of infection in the form of purulent secretions, sputum plugs or in this case, an unexpected finding of a calcified broncholithiasis secondary to Nocardia infection.

Exploitation of ATP-sensitive potassium ion (KATP) channels by HPV promotes cervical cancer cell proliferation by contributing to MAPK/AP-1 signalling

Persistent infection with high-risk human papillomaviruses (HPVs) is the causal factor in multiple human malignancies, including >99% of cervical cancers and a growing proportion of oropharyngeal cancers. Prolonged expression of the viral oncoproteins E6 and E7 is necessary for transformation to occur. Although some of the mechanisms by which these oncoproteins contribute to carcinogenesis are well-characterised, a comprehensive understanding of the signalling pathways manipulated by HPV is lacking. Here, we present the first evidence to our knowledge that the targeting of a host ion channel by HPV can contribute to cervical carcinogenesis. Through the use of pharmacological activators and inhibitors of ATP-sensitive potassium ion (KATP) channels, we demonstrate that these channels are active in HPV-positive cells and that this activity is required for HPV oncoprotein expression. Further, expression of SUR1, which forms the regulatory subunit of the multimeric channel complex, was found to be upregulated in both HPV+ cervical cancer cells and in samples from patients with cervical disease, in a manner dependent on the E7 oncoprotein. Importantly, knockdown of SUR1 expression or KATP channel inhibition significantly impeded cell proliferation via induction of a G1 cell cycle phase arrest. This was confirmed both in vitro and in in vivo tumourigenicity assays. Mechanistically, we propose that the pro-proliferative effect of KATP channels is mediated via the activation of a MAPK/AP-1 signalling axis. A complete characterisation of the role of KATP channels in HPV-associated cancer is now warranted in order to determine whether the licensed and clinically available inhibitors of these channels could constitute a potential novel therapy in the treatment of HPV-driven cervical cancer.

CREB1 activation promotes human papillomavirus oncogene expression and cervical cancer cell transformation

Human papillomaviruses (HPVs) infect the oral and anogenital mucosa and can cause cancer. The high-risk (HR)-HPV oncoproteins, E6 and E7, hijack cellular factors to promote cell proliferation, delay differentiation and induce genomic instability, thus predisposing infected cells to malignant transformation. cAMP response element (CRE)-binding protein 1 (CREB1) is a master transcription factor that can function as a proto-oncogene, the abnormal activity of which is associated with multiple cancers. However, little is known about the interplay between HPV and CREB1 activity in cervical cancer or the productive HPV lifecycle. We show that CREB is activated in productively infected primary keratinocytes and that CREB1 expression and phosphorylation is associated with the progression of HPV+ cervical disease. The depletion of CREB1 or inhibition of CREB1 activity results in decreased cell proliferation and reduced expression of markers of epithelial to mesenchymal transition, coupled with reduced migration in HPV+ cervical cancer cell lines. CREB1 expression is negatively regulated by the tumor suppressor microRNA, miR-203a, and CREB1 phosphorylation is controlled through the MAPK/MSK pathway. Crucially, CREB1 directly binds the viral promoter to upregulate transcription of the E6/E7 oncogenes, establishing a positive feedback loop between the HPV oncoproteins and CREB1. Our findings demonstrate the oncogenic function of CREB1 in HPV+ cervical cancer and its relationship with the HPV oncogenes.

m6A Regulates the Stability of Cellular Transcripts Required for Efficient KSHV Lytic Replication

The epitranscriptomic modification N⁶-methyladenosine (m⁶A) is a ubiquitous feature of the mammalian transcriptome. It modulates mRNA fate and dynamics to exert regulatory control over numerous cellular processes and disease pathways, including viral infection. Kaposi's sarcoma-associated herpesvirus (KSHV) reactivation from the latent phase leads to the redistribution of m⁶A topology upon both viral and cellular mRNAs within infected cells. Here we investigate the role of m⁶A in cellular transcripts upregulated during KSHV lytic replication. Our results show that m⁶A is crucial for the stability of the GPRC5A mRNA, whose expression is induced by the KSHV latent-lytic switch master regulator, the replication and transcription activator (RTA) protein. Moreover, we demonstrate that GPRC5A is essential for efficient KSHV lytic replication by directly regulating NFκB signalling. Overall, this work highlights the central importance of m⁶A in modulating cellular gene expression to influence viral infection.

Spontaneous pulmonary herniation in COVID-19

Spontaneous pulmonary hernia (SPH) is a rare condition. We report a case secondary to extreme coughing and COVID-19 infection. The patient displayed several clinical features typical of this diagnosis; difficult to manage pain on coughing, flank haematoma and bulging of the chest wall on coughing. Clinicians should be aware of the risk factors and clinical features of SPH to aid diagnosis of this rare condition.

Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis

BACKGROUND

To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques.

METHODS

A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm²) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed.

RESULTS

Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only.

CONCLUSION

Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.

Long-term trends in yield variance of temperate managed grassland

The management of climate-resilient grassland systems is important for stable livestock fodder production. In the face of climate change, maintaining productivity while minimizing yield variance of grassland systems is increasingly challenging. To achieve climate-resilient and stable productivity of grasslands, a better understanding of the climatic drivers of long-term trends in yield variance and its dependence on agronomic inputs is required. Based on the Park Grass Experiment at Rothamsted (UK), we report for the first time the long-term trends in yield variance of grassland (1965-2018) in plots given different fertilizer and lime applications, with contrasting productivity and plant species diversity. We implemented a statistical model that allowed yield variance to be determined independently of yield level. Environmental abiotic covariates were included in a novel criss-cross regression approach to determine climatic drivers of yield variance and its dependence on agronomic management. Our findings highlight that sufficient liming and moderate fertilization can reduce yield variance while maintaining productivity and limiting loss of plant species diversity. Plots receiving the highest rate of nitrogen fertilizer or farmyard manure had the highest yield but were also more responsive to environmental variability and had less plant species diversity. We identified the days of water stress from March to October and temperature from July to August as the two main climatic drivers, explaining approximately one-third of the observed yield variance. These drivers helped explain consistent unimodal trends in yield variance-with a peak in approximately 1995, after which variance declined. Here, for the first time, we provide a novel statistical framework and a unique long-term dataset for understanding the trends in yield variance of managed grassland. The application of the criss-cross regression approach in other long-term agro-ecological trials could help identify climatic drivers of production risk and to derive agronomic strategies for improving the climate resilience of cropping systems.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13593-023-00885-w.

OGC P43 Oncological outcomes following the introduction of laparoscopic gastric mobilisation during Ivor Lewis Oesophagogastrectomy within a regional Scottish centre

Background

Ivor Lewis Oesophagogastrectomy (ILO) is a potentially curative but highly morbid surgery. Minimally invasive techniques by comparison have demonstrated improved post-operative outcomes for patients. Hybrid laparoscopic gastric mobilisation (LGM) combined with an open right thoracotomy was introduced in our centre in 2019. This study assessed oncological outcomes between ILO with LGM and a fully open ILO, following this local change in operative technique.

Methods

This was a retrospective study of patients undergoing ILO at a single tertiary unit over a 5-year period (2017–2021). All patients undergoing open ILO were compared with those who had ILO with LGM. Resected lymph node count was used as a marker for oncological outcomes and median length of hospital stay a marker for post-operative outcomes.

Results

During the study period, 42 patients had open ILO and 32 had ILO with LGM. Patient demographics were similar between groups, with the majority receiving neoadjuvant chemotherapy (Open ILO 92.9% vs LGM 96.9%, p=0.629). Following local introduction of LGM in 2019, it immediately became the predominant method of gastric mobilisation during ILO (58% cases in 2019; 100% cases in 2020; 73% cases in 2021). Median total lymph node count resected was similar between LGM 17(15–25) vs open ILO 18 (16–24), p=0.643. Overall, length of stay was shorter in those having LGM compared to open (16 (11–21) vs 18 (11–36)), although this did not reach statistical significance (p=0.129).

Conclusions

Introduction of a hybrid minimally invasive technique for oesophagogastrectomy within our regional centre, has been associated with similar oncological outcomes to the traditional open approach. Further evaluation is required to ascertain the potential patient benefits of a LGM on post-operative outcomes within our patient cohort.

OGC P49 Case report: Ivor Lewis oesophagectomy requiring one lung ventilation in a patient with a previous laryngectomy

Background

A 68 year old patient with squamous cell carcinoma (SCC) of lower oesophagus (T3N0M0) presented for Ivor Lewis oesopphagectomy (ILO) following neoadjuvant chemoradiotherapy. Four years previously the patient had undergone total laryngectomy, radical right neck dissection with right pectoralis major flap and bilateral adjuvant radiotherapy for hypopharyngeal SCC (pT3N2bM0). A tracheal stoma was present with speaking valve in-situ. An ILO was planned requiring one lung ventilation (OLV) to facilitate surgical access. In our institution, OLV is routinely achieved via double lumen endotracheal tube (DLT), although endobronchial blocker through single lumen endotracheal tube or laryngeal mask airway and endobronchial intubation with a single lumen tube are potential options. Post laryngectomy the method used for lung isolation is limited and care must be taken not to traumatise the stoma site or surrounding tissue. Additionally, the angulation formed by the trachea and stoma mean a DLT is often not suitable while specific double lumen tracheostomy tubes may have too great a diameter for a small stoma. Surgically, close relations of the tumour to gastro-oesophageal junction, left diaphragmatic crus and descending thoracic aorta made suitability for resection uncertain, despite two negative staging laparoscopies. We describe the anaesthetic and surgical management of this interesting case.

Methods

General anaesthesia was delivered via an intravenous induction and maintenance was with sevoflurane. Airway management included bag mask ventilation with a neonatal facemask followed by placement of an 8mm reinforced endotracheal tube through the tracheal stoma. Prior to right thoracotomy a right sided 9Fr VivaSight endobronchial blocker (Ambu) was placed under direct vision using a single use Ambu aScope™ 4 Broncho Slim fibreoptic bronchoscope. OLV was successful using this method; SpO2 ≥96% (FiO2 0.6) and peak inspiratory pressure 18–20cmH2O-1. Analgesia comprised intrathecal morphine, right erector spinae plane local anaesthetic block and infusion catheter and morphine PCA. Abdominal phase was undertaken laparoscopically. The hiatus was noted to be fibrotic following chemoradiotherapy and a small capsular breach of the left lobe of liver occurred, controlled with Surgiflo (Ethicon). A right thoracotomy was performed through the 6th intercostal space. Right lung was deflated and surgical access was adequate. OrVil (Covidien – Medtronic) anastomosis was attempted but the anvil was unable to pass through the pharynx, therefore a purse string applicator was applied and OrVil staple used. The left pleura was also breached during dissection. One left and two right chest drains were placed.

Results

Postoperatively, analgesia was adequate and the patient did not require any cardiovascular or respiratory support. However, on first postoperative day it was noted that the speaking valve was not functioning causing significantly hoarse voice. A valve leak was detected and though hard to know the precise cause, it was assumed that it had become dislodged via either anaesthetic procedures, surgical handling or a combination. Despite some improvement in the symptoms over the first post-operative week, the patient also experienced airway soiling on commencing oral intake and after review by ENT a new valve was successfully sited and all symptoms resolved. Although a minor and easily rectifiable complication, the ‘loss of voice’ was very distressing for the patient.

The patient had an otherwise uneventful postoperative course and was discharged home on day-11. Clinic review at six weeks revealed the patient had made a complete recovery and had resumed all normal activities. Histology showed scattered small foci of moderately differentiated SCC infiltrating the muscularis propria (stage ypT2). Longitudinal margins were clear of both dysplasia and malignancy. There was no evidence of lymphatic, venous or perineural invasion. One of 12 lymph nodes showed metastatic SCC. Adjuvant course of Nivolumab immunotherapy is currently planned.

Conclusions

We have presented an unusual case of previous laryngectomy plus requirement for OLV for ILO. The use of an endobronchial blocker via a reinforced endotracheal tube has been shown to be a successful airway management strategy. Speaking valve displacement and/or malfunction is a potential complication in such cases and should form part of preoperative counselling.

Close liaison between surgical, anaesthetic and ENT teams is essential in the management of complex and unusual cases and, as we have demonstrated, strong teamwork leads to successful outcomes for patients.

EGS P14 Can preoperative Neutrophil-lymphocyte ratio predict post-operative complications in appendicectomy?

Background

Complications after appendicectomy remain common. Neutrophil-lymphocyte ratio (NLR) measures inflammation by incorporating the innate and adaptive components of the circulating immune system. We hypothesised that pre-operative NLR could predict post-operative complications after emergency appendicectomy.

Methods

A multicentre retrospective observational study was performed investigating all adults undergoing emergency appendicectomy across four hospital (2 teaching centres and 2 district general hospitals) between August 2018 and November 2020. Patients were identified through pathology records. Electronic records were studied for patient demographics, pre-operative routine laboratory tests, imaging, operative details, and post-operative complications. Neutrophil-lymphocyte ratio was calculated by dividing the pre-operative neutrophil count value by the lymphocyte value. A threshold of 8 was used based on previous literature.

Results

There were 1130 patients identified who underwent emergency appendicectomy, with 43.6% female. ASA level was I or II in 93.8% of patients, and 82.3% underwent a laparoscopic approach. Perforated appendicitis was observed in 21.7% of patients and two patients died. Mean NLR was 10.3 (SD 8.2), with 50.9% of patients with an NLR of &gt;8. NLR &gt;8 was associated with deep surgical site infections (SSI) (p &lt; 0.001). NLR &gt; 8 was predictive of deep SSI with an odds ratio of 3.455 (CI 1.840–6.488, p &lt; 0.001).

Conclusions

The NLR is an easy to calculate parameter which, when higher than 8, predicts deep surgical site infection following emergency appendicectomy and may help guide perioperative decision making such as antibiotic duration.

OGC P11 Recurrent laryngeal nerve injury after oesophagectomy: incidence, management and clinical sequelae

Background

Recurrent laryngeal nerve palsy (RLNP) resulting from injury during the cervical-stage of oesophagectomy is a recognised complication that can be associated with significant morbidity. This study aimed to investigate the incidence of RLNP within our local practice, to describe its management, short- and long-term sequelae.

Methods

Consecutive patients undergoing transhiatal oesophagectomy or 3-stage oesophagectomy with cervical anastomosis for both benign and malignant disease within a single UK regional centre between 1 January 2010 and 31 December 2019 were included from a prospectively collected database. Electronic records were interrogated and patients dichotomised into two groups – postoperative RLNP (paresis or paralysis) compared to no RLNP.

Results

182 patients were eligible for analysis. 33 patients (18.1%) developed RLNP after oesophagectomy. Patients with RLNP were significantly more likely to develop postoperative pneumonia (57.6% vs. 34.2%; p=0.017) and ARDS (9.1% vs. 0.7%; p=0.019), and were more likely to require ICU admission (30.3% vs. 14.8%; p=0.044). They were also found to have a longer length of hospital stay (24 vs. 15 days; p=0.001). 18 patients (54.5%) with RLNP required ENT review with 3 patients (9.1%) requiring vocal cord collagen injection. After a median 34 months (IQR 21.75-67) follow-up, 36.4% (12/33) patients had made a full and 42.4% (14/33) patients had made a partial recovery.

Conclusions

Judicious surgical technique in an attempt to avoid initial RLN injury, as well as proactive involvement of SALT and ENT specialists when injury does occur, are vital to reduce the significant pulmonary morbidity associated with this common complication of oesophagectomy.

Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis

BACKGROUND

Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase.

RESULTS

Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients).

CONCLUSION

Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.

Acetamiprid fate in a sandy loam with contrasting soil organic matter contents: A comparison of the degradation, sorption and leaching of commercial neonicotinoid formulations

The impacts of neonicotinoids have generally focussed on the responses of the pure active ingredient. Using a selection of two commercial formulations and the active ingredient, we ran three laboratory studies using ¹⁴C-labelled acetamiprid to study the leaching, sorption and mineralisation behaviours of the commercially available neonicotinoid formulations compared to the pure active ingredient. We added ¹⁴C-spiked acetamiprid to a sandy loam soil that had received long-term additions of farmyard manure at two rates (10 t/ha/yr and 25 t/ha/yr) and mineral fertilisers, as a control. We found significant differences in acetamiprid mineralisation across both the SOM and chemical treatments. Sorption was primarily impacted by changes in SOM and any differences in leachate recovery were much less significant across both treatment types. The mineralisation of all pesticide formulations was comparatively slow, with <23 % of any given chemical/soil organic matter combination being mineralised over the experimental period. The highest mineralisation rates occurred in samples with the highest soil organic matter levels. The results also showed that 82.9 % ± 1.6 % of the acetamiprid applied was leached from the soil during repeated simulated rainfall events. This combined with the low sorption values, and the low rates of mineralisation, implies that acetamiprid is highly persistent and mobile within sandy soils. As a highly persistent neurotoxin with high invertebrate selectivity, the presence of neonicotinoids in soil presents a high toxicology risk to various beneficial soil organisms, including earthworms, as well as being at high risk of transfer to surrounding watercourses.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Induction of APOBEC3-mediated genomic damage in urothelium implicates BK polyomavirus (BKPyV) as a hit-and-run driver for bladder cancer

Limited understanding of bladder cancer aetiopathology hampers progress in reducing incidence. Mutational signatures show the anti-viral apolipoprotein B mRNA editing enzyme catalytic polypeptide (APOBEC) enzymes are responsible for the preponderance of mutations in bladder tumour genomes, but no causative viral agent has been identified. BK polyomavirus (BKPyV) is a common childhood infection that remains latent in the adult kidney, where reactivation leads to viruria. This study provides missing mechanistic evidence linking reactivated BKPyV-infection to bladder cancer risk. We used a mitotically-quiescent, functionally-differentiated model of normal human urothelium to examine BKPyV-infection. BKPyV-infection led to significantly elevated APOBEC3A and APOBEC3B protein, increased deaminase activity and greater numbers of apurinic/apyrimidinic sites in the host urothelial genome. BKPyV Large T antigen (LT-Ag) stimulated re-entry from G0 into the cell cycle through inhibition of retinoblastoma protein and activation of EZH2, E2F1 and FOXM1, with cells arresting in G2. The single-stranded DNA displacement loops formed in urothelial cells during BKPyV-infection interacted with LT-Ag to provide a substrate for APOBEC3-activity. Addition of interferon gamma (IFNγ) to infected urothelium suppressed expression of the viral genome. These results support reactivated BKPyV infections in adults as a risk factor for bladder cancer in immune-insufficient populations.

P-OGC56 Do patients presenting with obstructing oesophageal cancer have worse outcome?

Background

Oesophageal cancer carries a poor prognosis.  Despite the availability of urgent Upper GI endoscopy in the United Kingdom, a substantial proportion of patients with newly diagnosed oesophageal cancer present late with near total dysphagia and an obstructing tumour at the index endoscopy.  There is little data analysing the effect of obstructing oesophageal cancer at presentation on overall prognosis.  The aim of the study was to analyse if patients presenting with obstructing oesophageal cancer have a worse outcome.

Methods

A retrospective cohort study of all newly diagnosed oesophageal cancers (adenocarcinoma and squamous cell carcinoma) and high grade dysplasia registered in a single UK Regional Upper GI MDT between October 2019 and September 2020 was performed.  Electronic records were interrogated and patients dichotomised into two groups based on if they were obstructed endoscopically or not on the index endoscopy and the results were compared.  Median follow up was 7 months.

Results

243 patients (68 (28.0%) obstructed and 175 (72.0%) non-obstructed) with median age of 70 were identified.  There were more females in the obstructed group (44.1% vs 25.7%, p = 0.005).  ECOG performance status was worse in the obstructed group: ECOG-0 (30.9% vs 50.3%, p = 0.006).   Adenocarcinoma was more common in non-obstructed group (69.1% vs 54.4%, p = 0.031).  More patients in the obstructed group had a T4 tumour (38.2% vs 18.9%, p = 0.002), however, nodal and metastatic status were similar.  Rates of curative intent treatment were similar.  At median follow-up of 7 months (IQR 3-13), more patients in obstructed group were deceased (72.1% vs 49.7%, p = 0.002).

Conclusions

Obstructing oesophageal cancer at presentation is a marker of advanced disease and despite curative treatment intent, overall survival is worse compared to passable tumours. New screening techniques such as Cytosponge combined with public health interventions to encourage early presentation may enable earlier diagnosis and improved survival.

P-OGC73 Effect of pyloroplasty on the need for endoscopic intervention for delayed gastric emptying post oesophagectomy

Background

Delayed gastric emptying (DGE) is a common complication following oesophagectomy, affecting 15-39% of patients. Controversy remains regarding the role of pyloric drainage procedures during oesophagectomy with gastric conduit reconstruction in reducing DGE. This study investigated the effect of pyloroplasty at the time of oesophagectomy on the need for endoscopic pyloric intervention post-operatively.

Methods

We performed a retrospective analysis of all oesophagectomies performed in a single tertiary centre over a 10-year study period between 1 January 2010 and 31 December 2019. Electronic records were reviewed to analyse patient demographics, operative details and post-operative outcomes, as well as the need for endoscopic procedures after surgery. Patients were dichotomized into two groups, with those who had pyloroplasty performed at oesophagectomy compared to those who did not. Patients who died ≤30 days after oesophagectomy were excluded from analysis. Patients were followed up for a median of 32 months (IQR 19-60). 

Results

298 patients were eligible for the study, of whom 80/298 (26.8%) had a pyloroplasty performed. Demographics were evenly matched between the two groups. Patients undergoing Ivor-Lewis oesophagectomy were significantly more likely to have had pyloroplasty performed (90.0% vs. 24.3%; p &lt; 0.001). Pyloroplasty had no significant effect on post-operative complication rates, ICU admission, need for re-operation or length of hospital stay. Patients without a pyloroplasty were significantly more likely to require endoscopic pyloric balloon dilatation (43.1% vs. 12.4%, p &lt; 0.001) or pyloric botox injection (12.4% vs. 3.8%, p = 0.029) after oesophagectomy.

Conclusions

In this study, patients who had a pyloroplasty at the time of oesophagectomy were significantly less likely to require endoscopic pyloric balloon dilatation and/or pyloric botox injection post-operatively. This has significant long-term implications for both patients’ quality of life post-operatively and demands on over-stretched endoscopic services.

O-OGC02 Stage Migration in Newly Diagnosed Oesophago-gastric Cancer during the first wave of COVID-19 Pandemic

Background

Covid-19 has significantly disrupted elective and emergency health care provision including cancer care within the UK. The aim of the study was to investigate the impact of the pandemic on the staging of oesophago-gastric cancers at presentation, determine the time delay in performing gastroscopy and the multidisciplinary team (MDT) treatment outcomes.

Methods

A retrospective cohort study of all newly diagnosed oesophago-gastric cancers (adenocarcinoma and squamous cell carcinoma) in a single regional MDT was performed between 1st October 2019 and 30th September 2020. Electronic records were interrogated and patients dichotomised into two groups with those presenting before the introduction of the UK national lockdown of 23^rd March 2020 compared to those presenting post-lockdown.

Results

349 new oesophago-gastric cancer patients were discussed in the MDT (192 pre-lockdown versus 157 post-lockdown). Demographics were evenly matched between the two groups. More patients presented as an emergency admission post-lockdown (28.0% vs 12.5%, p < 0.001). Median waiting time for gastroscopy was longer post-lockdown (23 vs 14 days, p = 0.035). Metastatic disease at presentation was more frequent post-lockdown (47.8% vs 33.3%, p = 0.008). Overall, more patients had a palliative rather than curative treatment intent post-lockdown (71.3% vs 57.8%, p = 0.005).

Conclusions

The Covid-19 pandemic has had a significant negative effect on the stage of oesophago-gastric cancers at presentation. This has translated into more patients receiving palliative treatment and ultimately having a poorer prognosis. This study highlights the importance of maintaining cancer services during the Covid-19 pandemic.

P-OGC74 Effect of pre-operative anaemia on short-term outcomes following oesophagectomy: a 10-year retrospective cohort study

Background

Pre-operative anaemia is associated with increased length of hospital stay, requirement for allogenic blood transfusion, post-operative complications and mortality. Oesophagectomy is a complex procedure associated with significant physiological insult, thus pre-operative patient optimisation is imperative to improve clinical outcomes. This study aimed to determine the impact of pre-operative anaemia on short-term outcomes following oesophagectomy for benign and malignant disease. 

Methods

A retrospective cohort study of all oesophagectomies performed in a single tertiary referral centre between 1 January 2010 and 31 December 2019 was performed. Patients were identified from a prospectively collected database and individual patient electronic records were interrogated. Patients were dichotomised into two groups, based on the most recent pre-operative haemoglobin. Patients with pre-operative anaemia (haemoglobin &lt;130mg/L in males and &lt;120mg/L in females) were compared to those without pre-operative anaemia. Patients with missing data were excluded from the study. Patients were followed up for a median of 32 months (IQR 18-66).

Results

Of 352 patients eligible for inclusion, 173 (49.1%) patients were anaemic immediately pre-operatively. Patients with pre-operative anaemia were older (66 vs. 64 years, p = 0.031), with a lower anaerobic threshold (11.7 vs. 12.3ml/min/kg, p = 0.011), and were significantly more likely to have undergone neoadjuvant chemotherapy (91.3% vs. 78.8%, p &lt; 0.001). Patient comorbidities and disease-related characteristics were similar between the two groups. Patients with pre-operative anaemia were significantly more likely to require post-operative blood transfusion (34.7% vs. 16.8%; p &lt; 0.001). However, pre-operative anaemia was not associated with increased post-operative complications, intensive care admission, length of hospital stay, or 30- and 90-day mortality rates following oesophagectomy.

Conclusions

Patients with anaemia immediately prior to undergoing an oesophagectomy were significantly more likely to require post-operative blood transfusion. However, pre-operative anaemia was not associated with an increased rate of post-operative morbidity or mortality. In addition, pre-operative iron transfusion is becoming increasingly utilised to minimise the incidence of pre-operative anaemia: this was not analysed in this study.

P-O08 Effect of socioeconomic deprivation on clinical characteristics and outcomes of patients undergoing an emergency appendectomy

Background

Appendicectomy is one of the commonest emergency general surgical operations performed.  Previous studies have shown that socioeconomic status (SES) impact outcomes in a number of diseases.  Currently, there is no study analysing the impact of SES on the outcome of appendectomy.   Our aim was to compare the clinical characteristics and outcomes of adults having an emergency appendectomy between deprived and less deprived SES groups.  

Methods

A multicentre retrospective observational study of all adult patients who had an emergency appendectomy across four hospitals (two district general and two tertiary care hospitals) between August 2018 and November 2020 was performed.  Patients were identified through pathology records.  Data was extracted from electronic records for demographics, pre-operative (peak) blood results, pre and post-operative imaging, operative details and the clinical outcomes.  Patient’s residential address was used to calculate Scottish Index of Multiple Deprivation (SIMD).  The patients were grouped by SIMD into a more deprived SES group (SIMD 1-5) and a less deprived SES group (SIMD 6-10) and results compared.

Results

A total of 1,105 patients (57.5% male) were included.  Median age was lower in the more deprived group (35 vs 40 years, p &lt; 0.001).   The less deprived group were more likely to be fitter: ASA-1 grade 51.6% vs 43.5%, p = 0.008.  There were fewer appendectomies in most deprived decile compared to the least deprived decile (5.2 vs 11.3 per 10,000 population per year, p &lt; 0.001).   There was no difference in inflammatory markers, pre-operative imaging, surgical approach, severity of appendicitis and the median length of stay (3 days).  However, there were more surgical site infection in the more deprived group (3.4% vs 0.9%, p = 0.006).

Conclusions

This study demonstrates that SES does impact on the age of presentation and incidence of appendectomy.  Surgical site infection were seen more frequently in the more deprived patients undergoing emergency appendectomy.  This may be a reflection of the underlying comorbidities.

P-O13 Spontaneous Splenic Rupture as first presentation of Chronic Myeloid Leukaemia

Background

Although rare, spontaneous splenic rupture (SSR) is a potentially life threatening condition and most commonly associated with infection and malignancy. Haematological malignancies are an important differential diagnosis and among these chronic myeloid leukaemia (CML) has one of the highest associations with SSR.

Methods

This case report follows a previously fit and healthy thirty-three year old gentleman who presented to accident and emergency with one day history of sudden onset, severe, left upper quadrant pain. CT of the abdomen and pelvis including an arterial phase, confirmed splenic rupture with moderate volume haemo-peritoneum, but no active bleeding. White cell count (WCC) was 225.8 x10^9/l and blood film confirmed suspicion of haematological malignancy. The patient was haemodynamically stable and therefore transferred to the surgical high dependency unit for observation and conservative management. He was commenced on hydroxycarbamide on the advice of haematology.

Results

Genetic screening detected BCR-ABL1 and Philadelphia chromosome; this along with bone marrow aspirate confirmed diagnosis of CML. His WCC decreased with hydroxycarbamide therapy. He made good clinical progress and was discharged home with haematology follow up. Hydroxycarbamide has since been stopped and he has been initiated on Imatinib therapy. His WCC has returned to normal and he has remained well with no further complications.

Conclusions

SSR is an extremely rare first presentation of CML. Given its associated morbidity and mortality, it should remain an important differential diagnosis in patients presenting acutely to the General Surgeon with abdominal pain and shock, especially in those with a known underlying haematological malignancy.

P-OGC72 Morbidity following oesophagectomy: the long-term re-operation rate after surgical resection in a Scottish tertiary centre

Background

Oesophagectomy remains the best curative option for early stage or locally advanced cancers of the oesophagus and gastro-oesophageal junction. The long-term morbidity associated with oesophagectomy is poorly understood. This study aimed to describe re-operation rates for oesophagectomy-related complications, performed beyond 90 days from index oesophagectomy.

Methods

A retrospective cohort study of all oesophagectomies performed in a single tertiary centre between 01 January 2010 and 31 December 2019 was performed. Electronic records were interrogated and patients dichotomised into two groups, with patients that underwent re-operation at ≥ 90 days after oesophagectomy for complications directly related to the index procedure compared to patients who did not have further surgery. All endoscopic interventions were excluded from analysis. The median length of follow-up was 34 months (IQR 20-67).

Results

343 patients were eligible for analysis. Patient demographics and index operative approach were similar between the two groups. Beyond 90 days from surgery, 8.7% of patients (30/343) required a further operation for complications directly related to oesophagectomy. The median time to re-operation was 15.5 months (IQR 12-29). 28 out of a total of 38 re-operations performed (73.7%) were for wound complications (including 15 incisional hernia repairs and 7 excision of stitch sinus). Development of a wound infection in the immediate post-operative period was associated with an increased rate of later re-operation (16.7% vs. 4.8%, p = 0.022).

Conclusions

A small but significant number of patients require re-operation following oesophagectomy beyond 90 days of surgery. This should form part of the pre-operative informed consent discussion in order to fully appraise patients and manage expectations. Reducing the incidence of early wound infection appears to be a key factor.

P-OGC69 Incidence, presentation and long-term sequelae of hiatus hernia after oesophagectomy: a 10-year retrospective cohort study

Background

Hiatus hernia after oesophagectomy is a rare but recognised event, with potentially life-threatening consequences when there is bowel compromise. This 10-year retrospective cohort study aimed to identify the incidence and evaluate the clinical presentation and long-term management of hiatus hernia after oesophagectomy.

Methods

We conducted a retrospective analysis of all oesophagectomies performed in a single tertiary centre over a 10-year study period between 2010 and 2019. Demographics, details of the initial procedure and long-term outcomes were analysed. Patients that underwent post-operative computed tomography (CT) imaging at ≥ 12 months post-operatively were included in analysis, with all CT scans independently reviewed by a radiologist.

Results

212 patients were eligible for analysis. 25% (53/212) of patients developed a hiatus hernia post oesophagectomy. Demographic data were similar between patients who developed a hernia compared to those who did not. 75.5% (40/53) of post-operative hiatus hernias developed after transhiatal oesophagectomy (p &lt; 0.001), and patients with post-operative hiatus hernia had a higher BMI (p = 0.009); this association was confirmed on multivariate analysis. Hiatus hernia was frequently under-reported, with only 58.5% (31/53) mentioned on the formal CT report. 81.1% of patients (43/53) were asymptomatic. Operative intervention was only performed in 1 patient presenting with small bowel obstruction as an emergency.

Conclusions

Hiatus hernia is a potentially clinically significant and under recognised long-term complication following oesophagectomy, with a significantly higher incidence following transhiatal oesophagectomy and in obese patients. With increasing long-term survival after surgical resection and its preponderance to be found incidentally on cross-sectional imaging, judicious screening for hiatus hernia is warranted to prevent fatal complications. 

P-OGC78 One year experience of a newly established super green ERAS pathway for performing oesophago-gastric cancer resections during the Covid-19 pandemic

Background

Surgical oncology services in the UK have been impacted by the COVID-19 pandemic.  Various strategies have been employed in an attempt to continue cancer resectional surgery   during the pandemic.  This study examined our institution’s experience and outcomes with a newly established Super Green ERAS pathway for oesophago-gastric (OG) cancer resections during the pandemic.

Methods

A retrospective cohort study of consecutive patients who had a resection for OG cancer performed over a 12-month period beginning from the date of the first UK National Lockdown of 23 March 2020.  Barring two intervals each lasting 3 weeks, urgent elective cancer surgery continued on our mixed hot and cold site through the establishment of a Super Green ERAS pathway.

Patients were confirmed COVID-19 negative within 72 hours pre-admission and retested  72-hourly post-op. 14 days self-isolation pre-admission was mandated.  Patients not complying had their surgery postponed. Transhiatal oesophagectomy was the preferred approach for oesophagectomy during the pandemic. 

Results

45 resections (33 oesophagectomies, 10 gastrectomies and 2 trial of dissections) were performed.  37 (82.2%) patients were male with a median age of 64 (IQR 58-71) years.   3 patients were postponed due to non-adherence with self-isolation.

No patients tested positive for COVID-19 post-operatively, hence, there was no COVID-19-related morbidity. Nine patients developed pneumonia. Seven patients had an anastomotic leak, all of whom were successfully rescued. One patient required a clamshell thoracotomy due to intra-operative mediastinal bleeding followed by a return to theatre for reconstruction 48hrs later.  Median length of stay was 12 (IQR 9-18) days. There was no in-hospital mortality.

Conclusions

OG cancer resections can be performed safely despite COVID-19, with favorable clinical outcomes when a Super Green ERAS pathway is strictly adhered to.   Implementation of such pathways will enable surgical oncology services, including OG cancer resections, to continue to ensure best possible outcomes for cancer patients despite any future waves of the COVID-19 pandemic.

P-O14 The predictive role of pre-operative liver function tests in outcomes following emergency appendicectomy

Background

Acute appendicitis remains one of the most common diagnoses in emergency general surgery, with recent evidence from the COMMA trial confirming that appendicectomy is the cornerstone of definitive management in most patients. With a wide range of severity and of patient physiology, complications are a burden to patients and the health service. We hypothesised that liver function tests have predictive value for complications following emergency appendicectomy.

Methods

A multicentre retrospective observational study was carried out across 4 hospitals (2 teaching centres and 2 district general hospitals) for adult patients who underwent emergency appendectomy between August 2018 and November 2020.  Patients were identified through pathology records and data was extracted from electronic case records for patient demographics, pre-operative routine laboratory results, operative details, and clinical outcomes. Peak perioperative liver function parameters were analysed using unpaired two-way T-tests, Pearson’s correlation coefficient, ANOVA and multivariate regression to determine their relationship with conversion to open surgery, superficial and deep surgical site infection (SSI), length of stay (LOS) and 30-day re-admission rates.

Results

Of 1131 patients included, 57.4% were male, 80.5% were laparoscopic, with 7.3% converted to open, 10.8% performed open, and 1.5% by laparotomy. Mean LOS was 3.81 (SD4.0) days, 6.3% readmission rate, with 2.3% superficial SSI and 5.0% deep SSI.

ALP was higher in patients with superficial SSI (p &lt; 0.001). Lower ALT was associated with wound dehiscence (p &lt; 0.001). Bilirubin, AST and ALT were lower in patients with chest infections (p &lt; 0.001). ALP correlated with increased LOS (p &lt; 0.001).

On multivariable regression, ALP was associated with superficial SSI (p &lt; 0.001), and LOS (p &lt; 0.001). ROC curve analysis demonstrated AUC of 0.655 for ALP and superficial SSI.

Conclusions

Emergency appendicectomy is completed laparoscopically in more than 80% of patients and complication rates are acceptable. Routine liver function tests were associated with important clinical outcomes including superficial SSI, wound dehiscence, chest infection, LOS and readmission rate. Patients who had superficial SSI, wound dehiscence, chest infection and readmission with 30 days had lower transaminase levels compared with those with uncomplicated recovery.

P-OGC77 Why curative treatment rates are so low for stage I/II Oesophago-gastric cancer in the West of Scotland? – A five year review

Background

Over the last decade, quality performance indicators (QPIs) have been used to drive improvements in cancer care in Scotland.  QPI-11 targets curative treatment rates for oesophago-gastric (OG) cancer and this target has been consistently missed.  This study aimed to investigate why patients with potentially curable Stage I and II OG cancer did not receive curative treatment. 

Methods

The West of Scotland MCN database was interrogated for patients with newly diagnosed stage I and II OG cancer between January 2015 and December 2019 to identify those patients who did not have curative treatment.  Electronic records were then analyzed and the reason for the non curative treatment recorded.

Results

260 patients (mean age 78.3 ± 9 years; 114 (43.8%) female) were identified. Median Scottish Index of Multiple Deprivation was 4 (IQR 2-7).   There were 159 (61.2%) oesophageal cancers, 196 (75.4%) adenocarcinomas and 174 (66.9%) were Stage II cancers.  Formal CPEX fitness was assessed in only 20 patients (7.7%).  Reasons for curative treatment not being received were as follows: not clinically fit (n = 216 (83.1%)); patient declined curative treatment (n = 17 (6.5%)); disease progression (n = 16 (6.2%)) and identification of synchronous cancers (n = 9 (3.5%)).

Conclusions

Lack of fitness for radical treatment is the predominant reason for Stage I and II OG cancer patients in the West of Scotland not being treated with curative intent.  This may be related to the previously described “West of Scotland” effect on health comorbidities.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

SP2.2.11Improving the quality of the documented weekend surgical handover: Implementation of a handover sticker within an urban teaching hospital

Aim

Effective, high-quality patient handovers between the surgical team are essential for safe transfer of responsibility for patient care whilst ensuring continued patient-safety and supporting good clinical governance. Weekend handovers provide a particular challenge, with error potential, when patients are cared for by multiple different healthcare professionals. This project aimed to improve the documentation of the weekend handover for the surgical inpatients of a busy UK teaching hospital.

Method

Quality Improvement project performed within a single General Surgical department between August and October 2020. An initial casenote audit on 3 consecutive Fridays compared available handover information against RCS guidance. A comprehensive surgical weekend handover sticker was designed and all members of the surgical team educated in its use. Following sticker introduction, handover quality was similarly re-audited. **=p&lt;0.00001 using Chi-squared/Fisher exact.

Results

138 inpatient records were evaluated in cycle 1 and 135 in cycle 2, with the proportion containing a weekend handover increased post-intervention (96 vs. 82%,p=0.0004). Handover quality improved following sticker introduction with more frequent documentation of: diagnosis (96 vs. 21%**); need for imaging review (94 vs. 29%**); intravenous fluid plan (84 vs. 21%**); blood test requirements (94 vs. 24%**); mode of nutrition (90 vs. 24%**); antibiotics (90 vs. 30%**); drug monitoring (90 vs. 1%**); discharge planning (94 vs. 44%**) and escalation plan (87 vs. 0%**).

Conclusion

Introduction of a sticker has significantly improved the quality of documented handover available to the responsible on-call team. Future work will assess sticker impact on quality of care and clinical outcomes.

EP.WE.410Appendicectomy during the COVID-19 pandemic: an assessment of the change in practice within the West of Scotland

Aims

The Covid-19 pandemic has significantly impacted emergency and elective surgical activities. Multiple surgical professional bodies initially recommended appendicitis be managed conservatively or with judicious open surgery to mitigate potential risks with Covid-19 transmission. This study compares the investigation, operative findings and outcomes of patients who underwent appendicectomy before and after the National lockdown.

Methods

A multicentre retrospective cohort study of patients who had emergency appendicectomy in four West of Scotland hospitals between September 2019 and November 2020. Electronic records were interrogated and patients dichotomised into two groups with those presenting before the introduction of the UK National lockdown of 23^rd March 2020 compared to those presenting post-lockdown.

Results

A total of 559 appendicectomies were performed (280 pre-lockdown and 279 post-lockdown) in four hospitals and included in the analyses. More males than females had appendicectomy in the post-lockdown period (60.6% vs 52.1%, p 0.044). Pre-operative CT scanning was performed more often post-lockdown (71.7% vs 56.8%, p < 0.001) and an open approach was adopted more frequently post-lockdown (19.0% vs 3.6%, p < 0.001). The proportion of operations for complicated appendicitis increased post-lockdown (31.9% vs 22.1%, p = 0.009). Median hospital stay was equal in both groups (3 vs 3 days, p = 0.787). Post-operative complication rates were similar in both groups apart from a higher 30-day re-admission rate post-lockdown (7.9% vs 3.6%, p = 0.028).

Conclusion

Covid-19 has resulted in significant modifications to the pre-operative work-up and surgical approach to patients undergoing emergency appendicectomy. Whilst the proportion of patients with complicated appendicitis has increased post-lockdown, overall clinical outcomes remain similar.

EP.FRI.692 Gender differences in the age and outcomes of appendicectomy patients

Aims

Appendicectomy is one of the commonest emergency General Surgical operations performed. However, there exists minimal published literature exploring whether there are differences between males and females undergoing appendicectomy.  This study aimed to investigate the demographics, pre-operative investigation, intra-operative findings and clinical outcomes between both genders having an emergency appendicectomy.

Methods

A multicentre retrospective cohort study of all patients who had an emergency appendicectomy within four UK hospitals between September 2019 and November 2020. Electronic records were interrogated and patients dichotomised by gender and the results compared.

Results

559 emergency appendicectomies (315 (56.4%) male and 244 (43.6%) female patients) were included.  Males undergoing appendicectomy were younger (median age: 33 vs 41 years, p &lt; 0.001).  American Society of Anaesthesiologists classification was equally matched.  Whilst no difference in mean white cell or neutrophil count was identified, C-reactive protein was lower (mean 108 vs 137, p = 0.001) and bilirubin higher (mean 21 vs 15, p &lt; 0.001) in male patients pre-operatively.  Pre-operative imaging was performed more often in females: ultrasound (16.0 vs 1.3%, p &lt; 0.001) and CT scan (69.3 vs 60.3%, p = 0.029).  Male patients underwent more open surgery (13.7 vs 8.2%, p = 0.043).  The intra-operative severity of appendicitis was equally matched.  No differences in overall hospital length of stay (median 3 vs 3 days, p = 0.183), post-operative complication rates or 30-day readmission rates were identified.

Conclusions

This study demonstrates that differences exist between males and females who have emergency appendicectomy in terms of age, use of pre-operative imaging and operative approach, however, clinical outcomes are similar.

Characterization of an x-ray tube-based ultrahigh dose-rate system for in vitro irradiations

PURPOSE

To present an x-ray tube system capable of in vitro ultrahigh dose-rate (UHDR) irradiation of small < 0.3 mm samples and to characterize it by means of a plastic scintillation detector (PSD).

METHODS AND MATERIALS

A conventional x-ray tube was modified for the delivery of short UHDR irradiations. A beam shutter system with a sample holder was designed and installed in a close proximity of an x-ray tube window to enable <1 s irradiations at UHDR. The dosimetry was performed with a small 0.5-mm long 0.5-mm in diameter PSD irradiated with 80, 100, and 120 kVp beams and beam currents of 1-37.5 mA. The PSD signal was recorded at frame rates of 20 and 50 fps for shutter exposure between 100 and 1125 ms. Irradiation reproducibility was studied with the PSD. The x-ray tube irradiation setup was modeled with Monte Carlo (MC) and dose on a surface of a phantom was also measured with films. The effect of dose delivery uncertainty to 300-μm spheroids due to positioning and spheroid size was evaluated.

RESULTS

MC simulations showed good agreement with PSD measurements acquired at both frame rates of 20 and 50 fps in terms of beam temporal profile. PSD-measured dose exhibited excellent linearity as a function of instantaneous dose rate from 3.1 to 118.0 Gy/s as well as shutter exposure time from 100 and 1125 ms for all investigated beam energies. PSD absorbed dose for the 80, 100, and 120 kVp beams agreed with MC simulations to within 5%. The total delivered doses ranged from 0.4 Gy for a 1-mA, 80 kVp beam, and 100 ms shutter exposure to 166.9 Gy for a 37.5-mA, 80 kVp beam, and a 1125 ms exposure. PSD irradiation reproducibility was < 0.5%. Simulated and measured dose fall off agreed and it was steep along the axis of the shutter slit (1%/0.1 mm) and with depth (2%/0.1 mm at 1-mm depth). Spheroid positioning uncertainty of 300 μm resulted in dose difference of < 3% for x and y shifts but up to 7% uncertainty for a z-shift parallel to the beam axis. A 16% difference in spheroid size resulted in <5% dose difference in spheroid absorbed dose.

CONCLUSIONS

We have presented a cost-effective x-ray tube-based system with a beam shutter designed for in vitro UHDR delivery and reaching dose rates of up to 118.0 Gy/s. The described shutter system can be easily implemented at other institutions, which might enable new researchers to investigate the radiobiology of UHDR irradiations in vitro.

Covered stents versus balloon angioplasty for failure of arteriovenous access: a systematic review and meta-analysis

INTRODUCTION

Patients with end-stage renal disease may require arteriovenous (AV) access in the form of arteriovenous fistulae (AVFs) or arteriovenous grafts (AVGs) for haemodialysis. AV access dysfunction requires intervention such as plain balloon angioplasty or covered stents to regain patency.

AIM

To systematically review and meta-analyse the patency outcomes of covered stents in failing haemodialysis AV access, compared with balloon angioplasty.

METHODS

The review was first registered on the International Prospective Register of Systematic Reviews (CRD42018069955) before data collection. We searched six electronic databases to identify relevant randomised controlled trials (RCTs) up until August 2020, without language restriction. Two reviewers assessed the suitability and quality of studies for inclusion using the Consolidated Standards of Reporting Trials guidelines. We meta-analysed data using a random-effects model.

RESULTS

We included seven studies including 1147 patients in the systematic review, of which 867 had AVGs and 280 had AVFs. One study was an ongoing RCT. In the meta-analyses, we assessed patients with failing AVGs only. Overall risk of bias was moderate. Covered stents were associated with lower loss of patency versus angioplasty alone at 6, 12 and 24 months (OR 4.48, 95% CI 1.98 to 10.14, p<0.001; OR 4.07, 95% CI 1.74 to 9.54, p=0.001; OR 2.24, 95% CI 1.17 to 4.29, p=0.01, respectively). Covered stents afforded superior access circuit primary patency compared with angioplasty alone at 6 and 12 months (OR 1.91, 95% CI 1.31 to 2.80, p<0.001; OR 1.97, 95% CI 1.14 to 3.41, p=0.02, respectively). This was not significant at 24 months. There was no significant difference in loss of secondary patency between groups at 12 or 24 months (OR 0.74, 95% CI 0.45 to 1.23, p=0.25; OR 0.67, 95% CI 0.29 to 0.154, p=0.34, respectively).

CONCLUSION

Our results support use of covered stents over angioplasty alone, at 6, 12 and 24 months in failing AVGs. Further clinical trials are warranted.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

536 Use of A Cost-Efficient Colonoscopy Simulation Model to Improve Endoscopy Skills During the COVID Pandemic

Introduction

The use of endoscopic simulators as a learning aid in surgical training has been well established. This has been emphasised during the challenging times of COVID-19. However, their utility for training is countered by the high cost of the equipment, with the most basic simulators costing upwards of £50,000.

Method

A simple polypectomy simulator model was created using a drain-pipe and surgical gloves. n = 9 junior doctors were timed in their ability to remove the 3 polyps from the simulator. The exercise was repeated over 6 sessions over the course of 3 weeks. Means were compared using ANOVA.

Results

There was a mean relative reduction of 75% in overall time taken to complete the task(p < 0.0001). This improvement was seen for both surgical trainees(p = 0.005) and FY1 novices(p < 0.0001) and junior doctors reported feeling more confident with basic Colonoscopic skills.

Conclusions

We have demonstrated an improvement in performance times across both surgical trainees and novices. In today’s era of COVID-19, when direct training opportunities may become more scarce, simple alternatives may become vital in ensuring progression of basic surgical skills such as endoscopy. This cheap polypectomy simulator can be easily re-created across surgical units and can be used as an adjunct to traditional endoscopic training

E6-mediated activation of JNK drives EGFR signalling to promote proliferation and viral oncoprotein expression in cervical cancer

Human papillomaviruses (HPV) are a major cause of malignancy worldwide, contributing to ~5% of all human cancers including almost all cases of cervical cancer and a growing number of ano-genital and oral cancers. HPV-induced malignancy is primarily driven by the viral oncogenes, E6 and E7, which manipulate host cellular pathways to increase cell proliferation and enhance cell survival, ultimately predisposing infected cells to malignant transformation. Consequently, a more detailed understanding of viral-host interactions in HPV-associated disease offers the potential to identify novel therapeutic targets. Here, we identify that the c-Jun N-terminal kinase (JNK) signalling pathway is activated in cervical disease and in cervical cancer. The HPV E6 oncogene induces JNK1/2 phosphorylation in a manner that requires the E6 PDZ binding motif. We show that blockade of JNK1/2 signalling using small molecule inhibitors, or knockdown of the canonical JNK substrate c-Jun, reduces cell proliferation and induces apoptosis in cervical cancer cells. We further demonstrate that this phenotype is at least partially driven by JNK-dependent activation of EGFR signalling via increased expression of EGFR and the EGFR ligands EGF and HB-EGF. JNK/c-Jun signalling promoted the invasive potential of cervical cancer cells and was required for the expression of the epithelial to mesenchymal transition (EMT)-associated transcription factor Slug and the mesenchymal marker Vimentin. Furthermore, JNK/c-Jun signalling is required for the constitutive expression of HPV E6 and E7, which are essential for cervical cancer cell growth and survival. Together, these data demonstrate a positive feedback loop between the EGFR signalling pathway and HPV E6/E7 expression, identifying a regulatory mechanism in which HPV drives EGFR signalling to promote proliferation, survival and EMT. Thus, our study has identified a novel therapeutic target that may be beneficial for the treatment of cervical cancer.

Complications and functional outcomes after ileo-anal pouch excision-a systematic review of 14 retrospective observational studies

PURPOSE

The ileo-anal pouch (IAP) has been the gold standard procedure for maintenance of bowel continuity after panproctocolectomy for ulcerative colitis, familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. However, the IAP has an estimated failure rate of 13% at 10 years post-procedure (Tulchinsky et al., Ann Surg 238(2):229-34, 2003), which can result in pouch excision (P.E.). This systematic review aims to synthesise all the available studies reporting post-operative outcomes of P.E. and its impact on patient quality of life (QoL), when available, which have not previously been summarised.

METHODS

PubMed, Embase, Medline and the Cochrane library databases were searched with terms 'Pouch AND excision' OR 'Pouch AND removal' OR 'Pouch AND remove' OR 'IAP AND excision'. All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. were included. Studies with < 5 patients, non-English studies and conference abstracts were excluded.

RESULTS

14 studies comprising 1601 patients were included. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9-40%) or surgical site infection (wound-2 to 30%; intra-abdominal collection-3 to 24%). The mortality rate was between 0.58 and 1.4%. QoL is generally lower in P.E. patients compared to the normal population across various QoL measures and P.E. patients often had urinary and sexual dysfunction post-operatively.

CONCLUSIONS

There is a substantial incidence of complications after P.E.; however, there is no evidence describing QoL pre- and post-P.E. Further longitudinal research comparing QoL in patients undergoing P.E. and other treatment options such as indefinite diversion is required to definitively assess QoL post-procedure.

The human papillomavirus oncoproteins: a review of the host pathways targeted on the road to transformation

Persistent infection with high-risk human papillomaviruses (HR-HPVs) is the causal factor in over 99 % of cervical cancer cases, and a significant proportion of oropharyngeal and anogenital cancers. The key drivers of HPV-mediated transformation are the oncoproteins E5, E6 and E7. Together, they act to prolong cell-cycle progression, delay differentiation and inhibit apoptosis in the host keratinocyte cell in order to generate an environment permissive for viral replication. The oncoproteins also have key roles in mediating evasion of the host immune response, enabling infection to persist. Moreover, prolonged infection within the cellular environment established by the HR-HPV oncoproteins can lead to the acquisition of host genetic mutations, eventually culminating in transformation to malignancy. In this review, we outline the many ways in which the HR-HPV oncoproteins manipulate the host cellular environment, focusing on how these activities can contribute to carcinogenesis.

The STREAM Trial (Prostatic Artery Embolization for the Treatment of Benign Prostatic Hyperplasia) 24-Month Clinical and Radiological Outcomes

PURPOSE

To establish factors predictive of success prior to Prostate Artery Embolization (PAE) with MRI imaging.

MATERIALS AND METHODS

A prospective cohort study of 50 patients with Benign Prostatic Hyperplasia (BPH) were treated with PAE in a single institution. Patients had moderate to severe symptoms of BPH refractory to medical management for at least 6 months. Patients were imaged with multiparametric MRI imaging pre-PAE and at 3 months, 12 months and 24 months post-PAE. Clinical success was measured with IPSS, IIEF and EQ-5D-5L quality of life questionnaires.

RESULTS

The technical success was 48/50 (96%).The mean age of the group was 67 (range 54-83). The mean IPSS score pre-PAE was 21 and at 24 months was 8 (p < 0.001). There was no deterioration in erectile function. The mean volume of the prostate post-PAE was reduced at 3 and 12 months post-PAE but not significantly different at 24 months. This did not correlate with the IPSS score. Patients with median lobe enlargement has similar symptomatic improvement as those without median lobe enlargement. Internally within the prostate patients with adenomatous-dominant BPH initially did better than patients with stromal enlargement; however, at 24 months patients with stromal enlargement of the prostate improved greatest. Initial volume of the prostate was not a good predictor of clinical success.

CONCLUSION

PAE is a safe and effective treatment strategy for treating men with BPH. Patients with Adenomatous BPH clinically do better until 12 months but not at 24 months. Initial prostate volume does not affect outcome, and patients with median lobe enlargement do as well as those without.

Rationally derived inhibitors of hepatitis C virus (HCV) p7 channel activity reveal prospect for bimodal antiviral therapy

Since the 1960s, a single class of agent has been licensed targeting virus-encoded ion channels, or 'viroporins', contrasting the success of channel blocking drugs in other areas of medicine. Although resistance arose to these prototypic adamantane inhibitors of the influenza A virus (IAV) M2 proton channel, a growing number of clinically and economically important viruses are now recognised to encode essential viroporins providing potential targets for modern drug discovery. We describe the first rationally designed viroporin inhibitor with a comprehensive structure-activity relationship (SAR). This step-change in understanding not only revealed a second biological function for the p7 viroporin from hepatitis C virus (HCV) during virus entry, but also enabled the synthesis of a labelled tool compound that retained biological activity. Hence, p7 inhibitors (p7i) represent a unique class of HCV antiviral targeting both the spread and establishment of infection, as well as a precedent for future viroporin-targeted drug discovery.