British Journal of Surgery

Dionísio, Daniela Venâncio; Fonseca, Cláudia; Bicho, Luís; Pupo, Alexandra; Marques, Hugo Pinto

doi: 10.1093/bjs/znae271.225pmid: N/A

BackgroundGastrocutaneous fistulas are rare but serious complications that can arise following the surgical treatment of necrotizing pancreatitis. This post-operatory complication can be refractory to conservative management and may be further aggravated by severe skin injuries and malnutrition. This case report describes the comprehensive and multidisciplinary approach of a challenging case of gastrocutaneous fistula, ultimately requiring re-intervention.MethodA 78-year-old female with a history of severe necrotizing pancreatitis underwent pancreatic necrosectomy by laparotomy. Postoperatively, she developed a gastric fistula, initially repaired with a double-layered suture. Recurrence led to a gastrocutaneous fistula with continuous gastric drainage and chemical burn of the surrounding skin. Initial conservative management included insertion of a nasogastric tube for gastric decompression, followed by placement of a PEG tube to redirect the drainage and prevent further skin damage and an esophagojejunal feeding tube to bypass the fistula and maintain nutrition. Nevertheless, the fistula persisted, resulting in significant skin erosion and deterioration of the patient’s condition.ResultsGiven the failure of conservative measures and a concurrent diagnosis of a pancreatic fistula, a surgical approach was deemed necessary. The patient was transferred to a specialized hospital center, where she underwent fistulectomy with partial gastrectomy and wound closure. Negative pressure wound therapy (NPWT) was applied to the ulcerated skin to promote healing. This approach led to the successful closure of the gastrocutaneous fistula and healing of the skin wound. The patient showed marked clinical recovery, with no signs of infection or fistula recurrence and the nutritional status was successfully managed through enteral feeding leading to a notable functional recovery.ConclusionThis case underlines the complexity of managing gastrocutaneous fistulas, demonstrating the efficacy of combining surgical and supportive therapies, serving as a reference for similar future cases and emphasizing the need for comprehensive management strategies for complex postoperative complications.

Khan, Amnah Ilyas; Mostafa, Omar; Sellahewa, Chaminda

doi: 10.1093/bjs/znae271.213pmid: N/A

BackgroundEmergency presentation of hiatal hernias can be life-threatening and is associated with high morbidity and mortality rates. Elective Laparoscopic hiatus and paraoesophageal hernias are commonly performed with fundoplication. However, emergency cases are often repaired without an anti-reflux procedure. We present our experience of emergency Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication in a District General Hospital (Russells Hall Hospital, RHH).Method6 cases of diagnosed hiatus/ paraoesophageal hernia that underwent Emergency fundoplication from 2019-2024.ResultsThe mean age of the patients was 74 (56-83). All patients had a pre-op CT scan to confirm the diagnosis. 4 patients (66%) had a Type 3 Hiatus hernia and 2 (33%) had a Type 2 classic paraosephageal hernia. All patients underwent Emergency Laparoscopic Hiatus / Para oesophagal hernia repair with fundoplication. 2 patients required mesh for the repair. The mean length of stay was 5 days (3-7). There were no intra or post-op complications and on follow up 1 patient had a recurrence of symptoms after 1 year requiring redo fundoplication.ConclusionThe choice of operation is mainly based on the patient’s clinical condition, the complexity of the hernia and the surgeon’s experience. Our experience at RHH shows that Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication is safe and feasible in patients with emergency presentation.

Brown, Oliver D; Aroori, Somaiah

doi: 10.1093/bjs/znae271.023pmid: N/A

BackgroundCommon bile duct stones (CBDS) are typically managed in two stages: Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). However, access to ERCP can be limited or require referral, has a high failure rate, often necessitates additional imaging, and may involve multiple procedures. Increasing evidence suggests that single-stage management, involving LC with intraoperative imaging and bile duct exploration when indicated, is cheaper, more effective, and reduces overall length of stay. British Society of Gastroenterology guidance states that it is a valid alternative to ERCP. This study aimed to determine whether clinical practice aligns with this evidence.MethodNational Health Service (NHS) Admitted Patient Care publications summarise Hospital Episode Statistics by financial year and are openly accessible. OPCS4 Procedure Codes were screened by two authors and categorised as “operative” or “endoscopic.” Codes detailing the management of CBDS or bile duct exploration were included, while ambiguous codes or those for non-stone indications were excluded. Data pertaining to these codes were extracted from the Admitted Patient Care publications for 2012 to 2022 and summarised in a Microsoft Excel spreadsheet. Trends were analysed using a Non-Seasonal Mann-Kendall Trend TestResultsA total of 249,475 procedures for CBDS were performed over the ten-year period, with a mean patient age of 67. Annually, the total number of procedures increased from 21,365 to 27,668 (p=0.002). Endoscopic procedures increased from 19,716 to 25,976 (p=0.002), while operative procedures remained stable (1,649 to 1,692, p=0.431). Consequently, the proportion of endoscopic management rose from 92.3% to 93.9% (p<0.001). The mean age of patients undergoing operative procedures was ten years younger than those undergoing endoscopic procedures (57 vs. 67 years)ConclusionDespite evidence and guidance supporting single-stage procedures, there is a trend towards endoscopic management of CBDS in the UK. This may be due to operational pressures on the NHS, including the sequelae of the COVID-19 pandemic, or reflect challenges within hospital culture, skill mix, or equipment availability.

Huttman, Marc; Smith, Alexander; Robertson, Harry; Purves, Rory; Biggs, Sarah; Dewi, Ffion; Dixon, Lauren; Kirkham, Emily; Jones, Conor; Ramirez, Jozel; Scroggie, Darren; Pathak, Samir; Blencowe, Natalie

Atluri, Lakshmi Malvika; Chong, Kenneth; Subar, Daren

doi: 10.1093/bjs/znae271.293pmid: N/A

BackgroundPostoperative pancreatic fistula (POPF) remains a significant complication post pancreaticoduodenectomy (PD). Recent publications show no increased incidence of POPF due to positive bile cultures. A literature search on PubMed did not show any review on the relevance of specific cultures and their exact incidence of POPF.POPF is defined as Drain Amylase greater than three times its serum level on or after postoperative day 3. A relatively benign clinical course is grade A, moderately unwell patients requiring medical/minimal intervention (grade B), and critically ill patients with sepsis, requiring invasive intervention (grade C). Grade B + C is defined as CR-POPF.MethodA retrospective single-centre analysis of all patients with pancreaticoduodenectomy between 2017 and 2021 was reviewed. The clinical data that were reviewed were age, gender, length of stay[LOS], tumour staging, mortality rates, Pancreatic duct[PD], Pre-op stenting, the documented incidence of POPF/CR-POPF, Intra-Operative Bile Cultures[IOBC] and antibiotic sensitivity.The primary outcome was POPF. Secondary outcomes were 90-day mortality, LOS, return to theatre, Postoperative haemorrhage (POPH), and organ-specific relevance of POPF. All data was analysed using SPSS IBM version 29. P< 0.05 was taken as clinically significant.Results100 patients were included in the study. The mean age was 68.8 (SD-9.5). The M: F ratio was 54:46. The mean postoperative length of hospital stay was 19.38 days. 48 patients (48%) were diagnosed with a POPF, among which, 22 patients (47.8%) developed a CR-POPF. 57 patients had a positive IOBC. The incidence of POPF in patients with Positive IOBC was 43/57(75.43%) and that was 5/43(11.62%) of the patients with Negative IOBC (P < .0001).10% of patients had postoperative haemorrhage (POPH). 9% had 90-day mortality. All 9% of patients who had a return to theatre had POPF.ConclusionUnivariate analysis and logistic regression demonstrated that a positive IOBC had a higher associated incidence of POPF who underwent PD, with Klebsiella being the most common and statistically significant[P<.005]. The most common antibiotic found to be sensitive was Gentamicin, which is 25 per cent and, in combination with Co-amoxiclav, was found to be sensitive in 21.8% of cases. However, this is a single-centre retrospective study with variable operative techniques for different patient groups. Further studies would be warranted before correlating any results to all populations of patients developing POPF post pancreaticoduodenectomy.

Kanani, Trisha; Millard, Alice; Robertson, Francis; Issa, Eyad; Bhardwaj, Neil; Malde, Deep; Dennison, Ashley; Garcea, Giuseppe; Isherwood, John

doi: 10.1093/bjs/znae271.064pmid: N/A

BackgroundIn March 2021, the Royal College of Surgeons of England published The Kennedy Report, an independent and powerful review addressing the critical issues surrounding equality, diversity and inclusion within the surgical profession. Chapter 5 of the review states that aspirations to become a surgeon can begin whilst at secondary school, yet students from diverse ethnic and social backgrounds felt discouraged by teachers who doubted their potential. We describe the development and implementation of a strategic careers outreach initiative across the state-funded secondary schools in our diverse community, aiming to engage and support aspiring surgeons early in their journey.MethodIn June 2023, The Aspire Initiative was launched as an independent entity supported by surgeons from the local Hepato-Pancreato-Biliary Unit and sponsorship from the Royal College of Surgeons of England. Targeting students aged 13 to 17, the initiative offers community open events, inspiring video content, surgical work experience for those over 16, and outreach careers assemblies. Between November 2023 and March 2024, 13 assemblies were delivered at various state-funded secondary schools across Leicester. These sessions were led by surgeons reflecting ethnic, gender, and socio-economic diversity. Students were invited to complete surveys before and after the assembly to assess their impact.ResultsThe pre-session survey, completed by 874 students from Years 8-11, revealed that 149 aspired to be doctors or surgeons, while 243 were considering this (n=392). Of the 392 students, 57% reported that their parents had not attended university. Only 19% had a good understanding of the medical school application process, and 21% knew about the support available. Furthermore, 31% felt knowledgeable about the daily responsibilities and training pathways of medical professionals. The post-session survey, with 420 responses, showed significant improvements: 91% gained a better understanding of a surgical career and 52% felt more inspired and motivated to pursue their aspirations.ConclusionThe Kennedy Report recommended that careers outreach to diverse communities should be planned for as a strategic priority. This study highlights the impact of such initiatives in state-funded secondary schools, showing how they provide students from diverse social backgrounds with crucial insights into surgical careers. These programs help students make informed decisions and inspire them to pursue their aspirations by connecting with relatable role models. We propose that engaging with students at the secondary school level offers an ideal opportunity for surgeons to foster and sustain professional relationships with a diverse future workforce, laying foundations for continued support and mentorship.

Brown, Oliver D; Sorrell, Lexy; Latour, Jos M; Aroori, Somaiah

doi: 10.1093/bjs/znae271.195pmid: N/A

BackgroundIncidental Gallbladder Cancer (iGBC) is a rare complication of cholecystectomy, with a UK incidence of 0.14-0.3%. Despite its rarity, most gallbladder specimens are analysed histologically. Some comparable countries undertake Selective Histological Analysis (SHA), selecting high-risk specimens for histology based on clinical judgement or postoperative inspection. However, evidence suggests a third of diagnoses can be missed with these approaches. Swedish and Dutch diagnostic scores incorporate few risk factors and are not generalisable to the UK. We present a protocol for a UK study aiming to develop a detailed diagnostic score for iGBC to reliably stratify patients by their risk of iGBC.MethodThis UK multicentre, cross-sectional, trainee-led study includes adult patients undergoing cholecystectomy for benign indications. It incorporates a feasibility study and an adaptive design, and has been submitted for ethical review. A parallel qualitative study will explore attitudes towards the risk of iGBC and the acceptability of SHA among patients and healthcare professionals. The feasibility phase will include 500 patients over six months, collecting data on patient risk factors for iGBC, preoperative investigations, operative findings, and histology results. Exclusion criteria include cholecystectomy as a secondary procedure, polyps over 5mm, and conditions known to increase the risk of biliary tract cancers.ResultsFollowing the feasibility phase, the recruitment rate and data completeness will be evaluated. Outcomes will be assessed against anticipated values, and collaborators will be surveyed to identify challenges with data collection. Necessary adjustments to the electronic case record form or overall protocol will be made, and the recruitment target will be recalculated based on an updated sample size calculation. When the study meets specified progression criteria, additional sites will be recruited, and data collection will continue to meet the required sample size. A detailed statistical analysis plan will be provided at a later date.ConclusionThis protocol describes a UK diagnostic modelling study aimed at developing a risk-stratification score for iGBC in patients undergoing routine cholecystectomy, identifying high-risk patients and facilitating SHA.

Mian, Areeb; Young, Robert; Lakah, Adil; Leptidis, Ioannis; Jones, Robert; Gordon-Weeks, Alex

doi: 10.1093/bjs/znae271.031pmid: N/A

BackgroundColorectal cancer liver metastasis (CRLM) has a heterogeneous outcome and improved prognostic biomarkers are needed to aid patient-tailored management. Here, we assess the value of Computer Tomography (CT)-guided radiomics in the prognostication of post-resection CRLM using data from two large tertiary referral centres in the UK.MethodPatient data was extracted from prospectively maintained databases of patients undergoing CRLM resection at two centres. CRLM and regions of interest from background normal liver were segmented. Radiomics features were extracted from portal venous phase CT images using open-source software. Feature selection techniques were applied. Machine learning models incorporating radiomic or clinical features, and their combination, were developed and assessed for mortality prediction at fixed time points. Cox proportional hazard regression was utilised for risk score generation to classify patients as high or low-risk for overall survival estimation. The models were evaluated on unseen testing data.ResultsRadiomics features (269) were generated from 959 metastases in 399 patients across the two sites. Models with combined clinical and radiomic features performed similarly to those with radiomic features alone, and often outperformed models with clinical features alone demonstrating good discrimination and risk prediction at 2 and 3 years. The computed radiomic scores allowed us to generate Kaplan–Meier curves which showed CRLM patients in the high-risk group had a lower overall survival vs the low-risk group(p<0.05). This risk-score independently predicted mortality in our multivariate Cox proportional-hazards model.ConclusionWe demonstrate a robust combination of CT-based radiomics features can predict CRLM outcomes across two different hospital sites. Our radiomic risk-scores predicts overall survival and can prognosticate patients into high and low risk groups. These findings support the prognostic utility of CT-based radiomics in patients undergoing resection of CRLM and provide rationale for further investigation in a prospective, multi-centre setting.

Patel, Agastya; Lancellotti, Francesco; Lambert, Joel; Kadamapuzha, Jacob; Satyadas, Thomas

doi: 10.1093/bjs/znae271.210pmid: N/A

BackgroundMedian arcuate ligament syndrome (MALS) is a recognized, but rare condition, which is characterized by compression of the celiac artery and ganglion by median arcuate ligament. The entity often presented with chronic post-prandial abdominal pain, vomiting, and weight loss. These patients often undergo comprehensive investigation prior to diagnosis of MALS. This report presents our experience and short-term outcomes of patients with laparoscopic release of MALS at our center.MethodBetween 2022-2024, five patients with MALS underwent laparoscopic release at a tertiary HPB center under a single surgeon (TS). Data on patient demographics, presenting symptoms and duration, preoperative diagnostic tests, intraoperative findings and complications, postoperative complications, symptom recurrence and follow-up were prospectively maintained. All patients were discussed at a tertiary Vascular and HPB MDT; MALS was confirmed on US doppler (USD) and CT angiogram (CTA) (fish-hook type configuration of Celiac Truck with post-stenotic dilatation).ResultsTwo male and three female patients, with a median (range) age of 41 (25-70) years, underwent laparoscopic MALS release. The median (range) preoperative symptom duration was 54 (24-67) months, with most common presentation of post-prandial abdominal pain and weight loss. The median (range) BMI was 19.61 (18.30-17.82). The median (range) operative time was 313 (166-330) minutes. One patient required conversion to open due to bleeding from celiac trunk. The median (range) LOS was 7 (4-7) days. No postoperative complications occurred. The median follow-up was 10 months. One patient re-experienced abdominal pain, with no evidence of recurrence on USD and CTA.ConclusionMedian Arcuate Ligament Syndrome should be considered as a differential in patients presenting with chronic post-prandial abdominal pain and weight loss. Thorough investigation (USD and CTA) along with discussion at Vascular MDT should be undertaken. Laparoscopic release of MALS is a safe and effective treatment option in this cohort.

Alam, Mushfique; Duckworth, Carrie; Howes, Nathan; Stephens, Nathan; Pritchard, Mark

doi: 10.1093/bjs/znae271.018pmid: N/A

BackgroundGastric adenocarcinoma remains a significant global health burden. For advanced disease, treatment remains multi-modal with neoadjuvant chemotherapy followed by resectional surgery. Although the FLOT4-AIO trial has established the regimen of 5-fluorauracil, Leucovorin, Oxaliplatin and Docetaxel (FLOT) as the gold standard, some patients demonstrate a poor or no response to treatment, resulting in adverse oncological outcomes. Currently there are no accurate biomarkers to assess or predict the treatment response to neoadjuvant therapy. This study aims to explore the potential of patient-derived organoids as a predictive model to assess the treatment response to neoadjuvant chemotherapy in gastric adenocarcinoma.MethodPatient derived organoids are a novel, 3 dimensional in-vitro model which recapitulates the different cells that constitute the tissue of origin. From June 2023 to June 2024, 25 patients with a confirmed diagnosis of gastric adenocarcinoma, were recruited for tissue acquisition for organoid generation. Endoscopic biopsies of cancer tissue taken during OGD and staging laparoscopy were used to generate organoids from each patient. Organoids were subsequently expanded to a sufficient volume to allow cytotoxicity assays in response to different doses of the FLOT regimen. The organoid cytotoxicity response was compared to the patients radiological and pathological response following treatment.ResultsOrganoids were successfully generated from 76% of recruited patients (n=19). Of these, 4 patients and were excluded due to being unfit for neoadjuvant chemotherapy, whilst 2 were excluded due to the confirmation of metastatic disease, precluding neoadjuvant treatment. Finally a single patient was excluded due to mortality during neoadjuvant treatment. Of the remaining organoids, 5 were subjected to FLOT treatment within 2 weeks of tissue acquisition. Organoids demonstrated unique dose response profiles following with statistically significant differences in the IC50 values (p =0.048). The organoid responses corresponded to the clinical responses demonstrated by the patient they were derived from.ConclusionIn conclusion, this study underscores the potential of patient-derived cancer organoids as a predictive model for assessing the response to neoadjuvant chemotherapy in gastric adenocarcinoma. The generation of organoids from a significant proportion of patients and the subsequent drug response testing within 2 weeks of tissue acquisition suggests this novel method has the potential to become a valuable tool for predicting patient-specific responses and guiding personalised treatment plans. As such, further research is warranted to further assess the validity of this model, refine the existing techniques and explore its potential integration into clinical practice.