A preoperative predictive tool to assess the need for staging laparoscopy in oesophagogastric cancer patients

INTRODUCTION

Staging laparoscopy (SL) has become commonplace in the preoperative staging pathway for oesophagogastric (OG) cancer. SL is often performed before curative treatment to examine for macroscopic peritoneal metastases (PM) or positive peritoneal cytology (PPC). The aim of this study was to develop an objective risk scoring system to predict both PM and PPC at SL.

METHODS

A prospectively collected and maintained database of all OG cancer patients treated between 2006 and 2020 was reviewed. Univariate and multivariate analyses were performed to identify risk factors for both PM and PPC at SL. A risk score was produced for both PM and PPC, and then validated internally.

RESULTS

Among 968 patients who underwent SL, 96 (9.9%) had PM and 81 (8.4%) had PPC at SL. Tumour site (p < 0.001), computed tomography (CT) T stage (p < 0.001) and N stage (p = 0.029) were significantly associated with PM at SL (p < 0.001). Tumour site (p < 0.001), biopsy histology (p = 0.041), CT T stage (p < 0.001) and N stage (p < 0.001) were significantly associated with PPC. The risk scoring model for PM included cancer site and CT T stage. This was successfully tested on the validation set (area under the receiver operating characteristic [AUROC] = 0.730). The risk scoring model for PPC included cancer site, CT T and N stage. This was successfully tested on the validation set (AUROC = 0.773).

CONCLUSIONS

The current risk scores are valid tools with which to predict the risk PM and PPC in patients undergoing SL for OG cancer and may help to avoid subjecting patients to unnecessary SL.

OGC P02 A comparison of body composition changes between the FLOT and MAGIC regimes in patients with locally advanced oesophageal cancer

Background

Recently, peri-operative FLOT (fluorouracil plus leucovorin, oxaliplatin, and docetaxel) chemotherapy has superseded the ‘MAGIC’ regimen (epirubicin, cisplatin plus fluorouracil or capecitabine) as standard of care for locally advanced oesophago-gastric adenocarcinoma. However, concerns have been raised regarding the toxicity profile of FLOT. This study aims to compare the changes in body composition between both regimens.

Methods

115 patients treated with FLOT (n = 61) or MAGIC (n = 54) who underwent an oesophagectomy for oesophageal or gastro-oesophageal junction (GOJ) adenocarcinoma between 2014 and 2020 at Queen Elizabeth Hospital, Birmingham, UK were analysed. Changes in body composition between pre- and post-neo-adjuvant chemotherapy were determined by analysis of computed tomography imaging.

Results

In both regimes, a large proportion of patients were sarcopenic prior to starting chemotherapy (FLOT 44.2%, MAGIC 44.4%; p=0.984). The percentage of patients who were sarcopenic increased post chemotherapy (FLOT 63.9%, MAGIC 57.4%; p=0.474). There was no significant pre vs post chemotherapy change in L3 skeletal muscle index in both regimes (FLOT 2.96 ± 4.03 vs MAGIC 2.76 ± 4.21; p=0.792). There was also no significant pre vs post chemotherapy change in L3 fat index in both regimes (FLOT 2.49 ± 22.6 vs MAGIC 5.78 ± 24.2; p = 0.453). Myosteatosis was observed in 44.3% of patients pre-FLOT and 42.6% of patients pre-MAGIC (p=0.857). This increased to 62.2% post-FLOT and 46.3% post-MAGIC (p=0.085). FLOT chemotherapy was associated with better tumour regression grade compared to MAGIC (p&lt;0.001).

Conclusions

A large proportion of patients with locally advanced oesophageal/GOJ adenocarcinoma were sarcopenic and had myosteatosis prior to starting chemotherapy. A further loss of muscle and fat occurs during chemotherapy but there was no significant difference in loss of fat or muscle across both FLOT and MAGIC regimes. However, patients treated with the FLOT regime had better pathological response as compared with MAGIC.

OGC P46 Positive Circumferential margins are associated with poorer survival following surgery in gastro-oesophageal junctional cancers

Background

Adenocarcinoma of the gastro-oesophageal junction (GOJ) remains a significant clinical problem that is increasing in incidence and is associated with a poor prognosis. The aim of this study is to determine the effects of the resection margins on survival and recurrence.

Methods

A retrospective study was conducted at our hospital from March 2001 till December 2022. All the patients that had oesophagectomy for gastro-oesophageal junctional (GOJ) adenocarcinoma were included in this study. Demography, staging, margins, type of neo-adjuvant chemotherapy and survival data were collected.

Results

Over the study, 174 patients had Gastro-oesophageal junctional adenocarcinoma.

42 of the patients had circumferential margins positive and 132 had negative circumferential margins.

The median for survival is 18 months in circumferential margins positive and 31 months for the circumferential negative patients with a P value of &lt;0.001

There were no patients with longitudinal margins positive enough to calculate any statical analysis

The median of recurrence is 13.4 months for the circumferential margins positive and 26.8 months for the circumferential margins negative patients with a P value on 0.003

Conclusions

The presence of any circumferential margin tumour will significantly affect the survival rate and recurrence rate.

Influence of body composition measures on chyle leak after oesophagectomy

Background

Chyle leak (CL) is an infrequent but potentially serious complication of oesophagectomy. Sarcopenia is an increasingly recognised prognostic factor in oesophageal cancer surgery. The aim of this study was to identify the influence of body composition measures on CL following oesophagectomy.

Methods

Patients who developed CL after oesophagectomy between January 2006–December 2020 were identified retrospectively from a prospectively maintained dataset. A control group of patients undergoing oesophagectomy, who did not experience chyle leak during the same time period, was also collected. Relationships between CL and demographics, operative factors and body composition measures were investigated as primary outcomes. Risk factors for severe CL were evaluated as a secondary outcome.

Results

There were 26 patients who developed a CL following an oesophagectomy. On univariate analysis, preoperative body mass index (BMI) (P=0.001), subcutaneous fat index (P=0.001) and total fat index (P=0.004) were significantly associated with CL. On multivariate analysis, a lower preoperative subcutaneous fat index was a significant independent predictor of CL (P=0.003). Sarcopenia, as an overall measure, was not found to be a significant predictor of developing CLs. No significant predictors of severe CL were identified.

Conclusions

A reduced preoperative BMI and body fat composition are risk factors for CL after oesophagectomy. Sarcopenia does not predict either the occurrence or severity of CL. This presents potentially modifiable risk factors for CL after oesophagectomy and emphasises the importance of physiological and nutritional optimisation before oesophagectomy.

P-BN40 Fundoplication following lung transplant: A retrospective cohort analysis

Background

Gastroesophageal reflux disease (GORD) in patients receiving a lung transplant has been associated with worsened graft function and decreased survival. This analysis aimed to identify whether fundoplication following lung transplant can improve graft function and overall survival.

Methods

patients undergoing lung transplantation between January 1993 and January 2020 were included. Data on oesophageal pH, manometry testing, post-transplant lung function testing and overall survival were collected. Cox-regression testing was used to analyse associations between oesophageal manometry and pH testing, fundoplication and overall survival.

Results

Of 345 patients who underwent a lung transplant, 20 patients also received fundoplication. 84 patients received oesopageal pH and manometry testing. Abnormal manometry was recorded in 41 patients. Average Demeester score was 28.45 for patients not receiving fundoplication and 37.28 for those receiving fundoplication. Average pre-operative reflux time was 8.6% for those not receiving fundoplication and 10.3% for those receiving fundoplication.

Of 20 fundoplications, 4 were carried out within 1 year of transplant and 12 within 2 years. 1 patient had a post-operative complication following fundoplication. 13 of 20 patients had a positive response to fundoplication, defined as a less than 10% decrease in FEV1 lung function at 2 years. Receiving fundoplication was associated with better overall survival (p = 0.024) as was total reflux time &lt;7% (p = 0.21).

Conclusions

Fundoplication is a safe operation after lung transplant with good outcomes. Fundoplication was associated with better overall survival on cox-regression analysis.

The psychosocial impact of surgical complications on the operating surgeon: A scoping review

Background and Aim

Surgical complications are common, and their management is an integral part of surgical care. The impact on the surgeon, the “second victim” is significant, particularly in terms of psychological health. The aim of this review is to describe the nature of psychosocial consequences of surgical complications on the surgeons involved.

Method

Following scoping review protocols, we set out to identify the evidence-base for psychosocial consequences on the operating surgeon, predominantly general surgeons, following surgical complications.

Results

This scoping review identified 19 articles, mainly survey and interview based (n = 8), with all but one article from first world countries. Seven articles reported on negative emotions or depressive behavioural responses. All original studies reported on difficulty in coping (37.5%), and a range of behaviours. There was little evidence for support structures or active interventions to aid the surgeon post complication.

Conclusions

The review suggests that the psychosocial impact, following a complication, is variable but affects every surgeon irrespective of the level of impact on the patient. The main variables differentiating impact are severity, and outcome of the complication and seniority of the surgeon. Reported emotions and behaviours were generally negative and persist across the surgeon's journey towards recovery. Surgeons who manage stress well exhibit largely constructive behaviours and actively work to recover. Identification of variables underpinning complications, and affected surgeons is paramount, as is the provision of services to support recovery. Efforts should be made to proactively prevent complications, via education, awareness and to formalise support processes.

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Surgical complications negatively impact the operating surgeon (the second victim).

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Negative emotions and behaviours manifested may persist throughout surgeon’s career.

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Surgeons’ reaction can negatively influence social and professional relationships.

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Range of factors affect coping and recovery, and the support sought tend not to focus on psychosocial aspects of coping.

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Need to develop management resources for surgeons to manage the psychosocial impact.

Suture Cruroplasty Versus Mesh Hiatal Herniorrhaphy for Large Hiatal Hernias (HHs): An Updated Meta-Analysis and Systematic Review of Randomized Controlled Trials

BACKGROUND

To explore the clinical outcomes, safety and effectiveness of suture cruroplasty versus mesh repair for large hiatal hernias (HHs) by an updated meta-analysis.

MATERIAL AND METHODS

Randomized controlled trials evaluating the effects of these 2 treatment modalities were searched from PubMed and other electronic databases between January 1991 and July 2018. The outcome variables analyzed included operating time, complications, recurrence of HH or wrap migration, reoperation, hospital stay and quality of life.

RESULTS

Five randomized controlled trials totaling 478 patients (suture=222, mesh=256) were analyzed. For reoperation variable, the odds ratio was significantly 3.26 times higher for the suture group. For recurrence of HH, the odds ratio for the suture group was nonsignificantly 1.65 times higher compared with the mesh group. Comparable effects were noted for all other variables.

CONCLUSIONS

Mesh repair seems to be superior to suture cruroplasty for large HH repair. Therefore, the routine use of mesh may be advantageous in selected cases.

Causes of recurrence in laparoscopic inguinal hernia repair

PURPOSE

Recurrence after laparoscopic inguinal herniorrhaphy is poorly understood. Reports suggest that up to 13% of all inguinal herniorrhaphies worldwide, irrespective of the approach, are repaired for recurrence. We aim to review the risk factors responsible for these recurrences in laparoscopic mesh techniques.

METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English language, peer reviewed articles on the causes of recurrence following laparoscopic mesh inguinal herniorrhaphy published between 1990 and 2018. The search terms included 'Laparoscopic methods', 'Inguinal hernia; Mesh repair', 'Recurrence', 'Causes', 'Humans'.

RESULTS

The literature revealed several contributing risk factors that were responsible for recurrence following laparoscopic mesh inguinal herniorrhaphy. These included modifiable and non-modifiable risk factors related to patient and surgical techniques.

CONCLUSIONS

Recurrence can occur at any stage following inguinal hernia surgery. Patients' risk factors such as higher BMI, smoking, diabetes and postoperative surgical site infections increase the risk of recurrence and can be modified. Amongst the surgical factors, surgeon's experience, larger mesh with better tissue overlap and careful surgical techniques to reduce the incidence of seroma or hematoma help reduce the recurrence rate. Other factors including type of mesh and fixation of mesh have not shown any difference in the incidence of recurrence. It is hoped that future randomized controlled trials will address some of these issues and initiate preoperative management strategies to modify some of these risk factors to lower the risk of recurrence following laparoscopic inguinal herniorrhaphy.

Free Intraperitoneal Gallstone: An Unusual Case of Small Bowel Obstruction from Extrinsic Compression

Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it.

Research during medical school: is it particularly difficult in developing countries compared to developed countries?

OBJECTIVES

Medical student involvement in research has been declining over the years. We reviewed the factors that hinder participation in research with a focus on developing countries.

METHODS

Literature search was performed using PubMed, MEDLINE and Cochrane Library. Peer-reviewed articles published between 1995 and 2017 were screened for relevance to identify key factors affecting medical student involvement in research with a particular focus on developing world. Analytical review is presented here in this article in relation to commonly reported aspects related to research during medical school.

RESULTS

This search revealed varied contributing factors that hinder students' growth and interest in research. It commonly highlighted few aspects in relation to research during medical school, and they were "variability in research uptake among students and issues related to them, their knowledge and attitude toward research and organizational input and its influence on students".

CONCLUSION

While early introduction to research by inculcating a mindset aimed at research has been proposed, it has not been seen in practice during either the medical school or beyond to an extent that was expected. It appears that developing countries, while they share some of the reasons with developed countries, have their own set of difficulties, which are influenced by culture, beliefs and priorities.

A New Era of Minimally Invasive Surgery: Progress and Development of Major Technical Innovations in General Surgery Over the Last Decade

Minimally invasive surgery (MIS) continues to play an important role in general surgery as an alternative to traditional open surgery as well as traditional laparoscopic techniques. Since the 1980s, technological advancement and innovation have seen surgical techniques in MIS rapidly grow as it is viewed as more desirable. MIS, which includes natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), is less invasive and has better cosmetic results. The technological growth and adoption of NOTES and SILS by clinicians in the last decade has however not been uniform. We look at the differences in new developments and advancement in the different techniques in the last 10 years. We also aim to explain these differences as well as the implications in general surgery for the future.

Complications, Implications, and Prevention of Electrosurgical Injuries: Corner Stone of Diathermy Use for Junior Surgical Trainees

Diathermy is commonly used in modern-day surgery. The incidence of electrosurgical injuries related to diathermy is under reported, as it is difficult to ascertain the true impact on both patient and healthcare professionals. As junior surgical trainees, understanding of the mechanism and biophysics of the electrosurgical tools enables safer usage and contributes to improved outcome. Careful use of electrosurgical tools during operation and appropriate communication amongst staff members are pivotal to a safe surgical outcome. Here, we discuss the causes and risk factors regarding electrosurgical complications along with suggestions to ensure safe practice, focusing on commonly neglected areas.

Technical problems during laparoscopy: a systematic method of troubleshooting for surgeons

Background:

Laparoscopic surgery has progressed rapidly since the early 1990s. For some surgical operations, it has become the standard of care to the extent where open surgery is sometimes looked down upon by some surgical colleagues as well as by patients.

Current status:

Despite this widespread adoption and acceptance, many surgeons struggle to understand how the laparoscopy stacks work despite having the skills to perform the operation. Most hospitals rely on operating theatre assistants to troubleshoot in the event of problems. This could be potentially unsafe for patients if laparoscopic vision or pneumoperitoneum is lost at a critical point of the operation.

Discussion:

There are a number of approaches that have been published for troubleshooting laparoscopy stack. We explore and discuss some of them along with their advantages and disadvantages and how they relate to our methodology and approach. As a product of the discussion, we suggest a systematic way forward to troubleshooting laparoscopic tower equipment problems.

Conclusion:

The technical knowledge of surgeons and trainees varies widely in the area of laparoscopy-related troubleshooting. This systematic, practical algorithm would help and guide all surgeons to adopt a uniform approach, thereby improving patient safety.

Mastery learning: how is it helpful? An analytical review

The desire to be good at one's work grows out of the aspiration, competition, and a yearning to be the best. Surgeons, in their aim to provide the best care possible to their patients, adopt this behavior to achieve high levels of expert performance through mastery learning, and the surgical training attempts to prepare them optimally to lead a virtuous and productive life. The proponents of the framework reject evidence that suggests that other variables are also necessary to achieve high levels of expert performance. Here, we review various models and designs to achieve mastery along with their pros and cons to help us understand how mastery learning is helpful in surgical practice.

Self-regulated learning: why is it important compared to traditional learning in medical education?

Self-regulated learning has played an increasingly significant role in medical education over the last one to two decades. Medical educators have endeavored to ensure that the students are equipped to face the challenges of continued growth of medical knowledge. Here we enquire and reflect on various aspects of self-regulated learning including its strengths and weaknesses. We investigate how it could be incorporated with traditional teaching to bring the best out of the students and what students think about it.