• Assessment of long-term graft function following total pancreatectomy and autologous islet transplantation: the Leicester experience

  Pollard, Christina A; Chung, Wen Yuan; Garcia, Guiseppe; Dennison, Ashley R (2023-10-01)

  Background: Total pancreatectomy and islet autotransplantation (TPIAT) is a recognised treatment for chronic pancreatitis (CP) with the potential to mitigate or prevent pancreatogenic diabetes. We present our 10-year follow-up of TPIAT patients. Methods: The University Hospitals of Leicester performed 60 TPIAT procedures from September 1994 to May 2011. Seventeen patients completed their 10-year assessment and were grouped using the modified Auto-Igls criteria; good response, n=5 (insulin-independent for first 5 years post-TPIAT); partial response, n=6 (insulin requirements <20 iU/day post-TPIAT) and poor response, n=6 (insulin requirements ≥20 iU/day post-TPIAT). C-peptide, haemoglobin A1c (HbA1c) and oral glucose tolerance test (OGTT) were undertaken preoperatively (baseline), then at 3, 6 months and then yearly for 10 years. Data was analysed using analysis of variance (ANOVA). Results: Median C-peptide levels were significantly higher, 120 minutes following OGTT, in the "good response" compared to "partial" and "poor" groups (two-way ANOVA test, P<0.0001). All groups demonstrated preservation of C-peptide release. HbA1c levels were significantly lower in the "good response" compared to "partial" and "poor" groups (two-way ANOVA test, P<0.0003 and P<0.0001). Median fasting glucose levels at 30 and 120 min following OGTT, were significantly lower in the "good response" compared to "partial" and "poor" groups (two-way ANOVA test, P<0.0001 and P<0.0001). Conclusions: TPIAT preserves long-term islet graft functions in 10-year follow up. Even in patients in the poor response group, there is evidence of C-peptide release (>0.5 ng/mL) after OGTT stimulation potentially preventing long-term diabetes-related complications.
• Variation in treatment of intrahepatic cholangiocarcinoma: a nationwide multicentre study

  Bhardwaj, Neil (2023-08-23)
• Outcomes of Early Oral Feeding Compared to Delayed Feeding in Children after Elective Distal Bowel Anastomosis

  Eradi, Bala (2023-09)

  Background: Conventionally, oral feeds after distal bowel anastomosis surgery (ileostomy/colostomy closure) are delayed until after bowel peristalsis is established. The safety of an early feeding regimen is not established in children. This study compared early feeding regimens with delayed feeding in children undergoing elective intestinal anastomosis surgeries. Materials and methods: In this retrospective multicentric cohort study, children undergoing elective distal bowel anastomosis surgery were divided into Group A (oral feeds allowed within 6 h) and Group B (delayed feeds). The two groups were compared for the incidence of abdomen distension, vomiting, surgical site infection, duration of analgesia, length of hospital stay, and readmission rate. Results: During the study, 58 patients were included: Group A (n = 26) and Group B (n = 32). The duration of analgesia (1.9 vs. 4.01 days) and length of hospital stay (3.38 vs. 5.0 days) were significantly less in Group A. Abdominal distension (7.7% vs. 15.6%), vomiting (11.5% vs. 15.6%), surgical site infection rate (3.8% vs. 12.5%), and readmissions (0% vs. 3.1%) were less in Group A, but statistically not significant. Conclusion: Early feeding after the elective restoration of distal bowel continuity can be safely practiced in the pediatric population. It is associated with a reduced need for analgesia and shorter hospital stay.
• The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients

  Lee, Hayun; Makanji, Dipak; Ranjha, Khadija; Kukreja, Yuvraj (29/09/2023)

  Objectives: Post cholecystectomy pain syndrome can cause significant distress, impairs quality of life and exacerbations often result in emergency visits. Poorly controlled postoperative pain is a recognized cause of persistent postsurgical pain. Abdominal myofascial pain syndrome is an underdiagnosed cause of persistent pain in this cohort. The objective was to estimate the incidence of poorly controlled postoperative pain in the first 48 h after surgery and the likelihood of developing persistent pain at 12 months. Methods: The patients undergoing laparoscopic cholecystectomy at a tertiary unit were consented for participation in a prospective service evaluation. A telephone review was performed at three, six and twelve months after surgery. Incidence of poorly controlled pain in the first 48 h after surgery was assessed. Patients with persistent pain were referred to the pain clinic. Results: Over a six-month period, 200 patients were assessed. Eleven patients were excluded (5.5 %). Twelve patients were lost to follow-up (6.6 %, 12/189). Patient satisfaction with acute postoperative pain management was low in 40 % (76/189). Poorly controlled postoperative pain was reported by 36 % (68/189) of patients. Incidence of persistent pain was 29 % (54/189) at 12 months post-surgery. Over half of patients with persistent pain (63 %, 34/54) reported poorly controlled postoperative pain. A somatic source was diagnosed in 54 % (29/54) with post cholecystectomy pain syndrome. Conclusions: Poorly controlled postoperative pain was reported by a third of patients. Persistent pain was present in 29 % at twelve months post-surgery. Abdominal myofascial pain syndrome should be considered as a differential diagnosis in post cholecystectomy pain syndrome. Keywords: abdominal myofascial pain syndrome; abdominal wall pain; laparoscopic cholecystectomy; post cholecystectomy syndrome; postoperative pain.
• Revisional surgery following one anastomosis gastric bypass: the devil is in the details

  Sahloul, Mohamed (2023-07-06)

  Introduction Gastric bypass procedures are usually well tolerated and rarely require reversal. Literature regarding indications for reversal and outcomes is limited and largely restricted to Roux-en-Y gastric bypass (RYGB) [1,2,3,4,5]. Indications include food intolerance, malnutrition/excessive weight loss, dumping syndrome, postprandial hypoglycaemia, chronic pain, non-healing marginal ulcers and short bowel syndrome [1, 3, 5]. Over the years, the popularity and acceptance of one anastomosis gastric bypass (OAGB) has grown worldwide. Currently, it is estimated that OAGB accounts for more than 10% of the bariatric and metabolic surgical procedures performed worldwide [6]. The data on the reversal of OAGB is not only scant but also limited to malnutrition. The aim of this video is to demonstrate surgical pitfalls whilst performing OAGB or reversal of OAGB and to establish the merits of multidisciplinary approach and intraoperative endoscopy during complicated revisional surgery. Materials and Methods The video presents a laparoscopic revision of a complicated and previously inadequately reversed OAGB in a 65-year-old female patient. Initial OAGB, done elsewhere, was reversed 7 days postoperatively due to complete intolerance to liquids. The patient had a poor functional outcome with ongoing vomiting and excess weight loss of more than 100% due to poor oral intake. She was referred to our centre 10 months following her initial procedure with a BMI of 24 kg/m2. Intra-operatively, the OAGB gastric pouch was found to be communicating with the remnant stomach only through a very narrow side-to-side anastomosis, in agreement with the preoperative barium studies and cross-sectional imaging. This anastomosis was extended proximally up to the level of the gastric fundus to allow wide communication of the pouch with the body of the stomach. Intra-operative endoscopy revealed further stenosis at the body-antrum transition—presumably the result of the first horizontal stapling reaching too close to the greater curvature during the creation of the gastric pouch for the OAGB. This narrowing was not completely visualised in the preoperative studies. This narrow isthmus was widened by creating a side-to-side body-to-antrum anastomosis. Endoscopic views verified complete luminal reconstruction of the stomach. The alternative conventional approach to the procedure performed would have been a standard RYGB with/without fundal resection, but the patient was adamant against having any further bypass procedures. Results Τhe patient had an uneventful postoperative recovery and was discharged on day 7. She had a slow progression through textures and had difficulties fully tolerating solid nutrition with occasional vomiting. A nuclear solid gastric emptying study 4 months postoperatively revealed mild gastroparesis. This clinically resolved over the course of the following 8 months. At 5 years follow-up, the patient is tolerating an unrestricted solid diet with no evidence of malnutrition, whilst maintaining a BMI of 26 kg/m2. Conclusions OAGB is a commonly performed bariatric procedure. Although considered technically less challenging as compared to RYGB, care must be taken to avoid dividing the pouch too close to the greater curve. Reversal procedures are challenging, and a multidisciplinary approach in conjunction with intraoperative endoscopy is essential to fully assess the anatomy and avoid pitfalls. Bariatric teams must be prepared that despite complete anatomical reconstruction, physiological reversal of gastric function may be slow or even incomplete in some cases.
• Use of patient reported experience measure and patient reported outcome measures to evaluate differences in surgical or non-surgical management of humeral shaft fractures

  Athanatos, Lambros; Pandey, Radhakant; Singh, Harvinder (2021-10-26)

  Background: The aim of this study was to evaluate the use of patient reported experience measures (PREMs) in humeral shaft fractures managed with or without surgery against patient reported outcome measures (PROMs). Methods: Adult patients treated for a humeral shaft fracture between June 2015 and August 2017 were included in non-surgery and surgery (early and late surgery) groups. The PREM questionnaire was based on patient and clinician feedback obtained during focus groups and was posted to patients. PROMs included the short form-12 (SF-12) and visual analogue scale (VAS) for pain, stiffness, function and satisfaction. Results: Eighty-one patients responded, 54 patients were treated in a brace and 27 with surgery (13 early, 14 late). There was moderate positive correlation between PREM and VAS satisfaction and function and moderate negative correlation with VAS pain and stiffness. There was also moderate positive correlation between PREM and SF-12 mental and weak positive correlation with SF-12 physical. The late surgery group had poorer PREMs (expectations, p = 0.002 and friends & family test, p = 0.0001) and PROMs (VAS satisfaction, p = 0.005) compared to the early surgery group. Conclusions: PREMs can be used in conjunction with PROMs to improve the patient's quality of care and as a means of identifying, at an early stage, those patients not doing well and to offer surgery.
• Comparing the efficacy and safety of combination triamcinolone acetonide and 5-fluorouracil versus monotherapy triamcinolone acetonide or 5-fluorouracil in the treatment of hypertrophic scars and keloids: A systematic review and meta-analysis

  Mavilakandy, Akash (2023-06-20)

  Background: Keloids and hypertrophic scars cause physical and psychosocial problems. Combination 5-fluorouracil (5-FU) with triamcinolone acetonide (TAC) may enhance the treatment of pathological scars, although the evidence base is limited. Objectives: We aimed to evaluate the efficacy and complication rates of combination intralesional TAC and 5-FU in comparison to monotherapy intralesional TAC or 5-FU for the treatment of keloids and hypertrophic scars. Methods: EMBASE, MEDLINE and CENTRAL were searched by two independent reviewers. The primary outcome was treatment efficacy (51% to 100% improvement). Study quality and risk of bias were assessed using Cochrane's risk of bias tool, respectively. Results: Of 277 articles screened, 13 studies were included comprising 12 randomised control trials (RCT) and 1 non-randomised study. There were six and nine studies comparing combination intralesional therapy versus monotherapy 5-FU and monotherapy TAC, respectively. The combined group demonstrated superior objective treatment efficacy compared to the monotherapy TAC group (OR 3.45, 95% C.I: [2.22-5.35], I 2=0%, P<0.00001) and monotherapy 5-FU group (OR 4.17, 95% C.I: [2.21-7.87], I 2=0%, P<0.0001). Telangiectasia was less frequent in combination therapy (OR 0.24, 95% CI: [0.11-0.52], I 2=0%, P=0.0003) compared to monotherapy TAC. Conclusions: Combined intralesional TAC and 5-FU administration demonstrated superior treatment efficacy outcomes compared to monotherapy TAC or 5-FU. Patient-reported outcome measures, lacking here, should be incorporated in the design of future research to justify clinical recommendations.
• Computed tomographic colonography for symptomatic patients: the diminutive polyp dilemma

  Sharma, Vivek (2022-11-09)

  Background: Computed tomographic colonography (CTC) is sensitive to polyp detection but is considered inaccurate for measuring diminutive polyps (<6 mm), with divergence between CTC and either colonoscopic or histopathological polyp measurements. Reporting diminutive polyps remains debatable. This study aims to compare outcomes of symptomatic patients with diminutive versus borderline polyps on CTC and to thereby examine the potential implication of reporting diminutive polyps. Methods: A single-centre retrospective study of symptomatic patients who underwent CTC from October 2016 through September 2018 was performed. After excluding CTC demonstrating cancer, no polyps, or polyps >6 mm, cases were categorized as either 'diminutive' (largest polyp <6 mm), or 'borderline' (largest polyp = 6 mm). The outcome measures were progression to endoscopy, surgery, procedure-related morbidity, dysplasia and malignancy. Results: A total of 308 cases (211 diminutive and 97 borderline) were analysed. The groups were similar (P > 0.05) in mean age (73 vs. 74 years), female proportion (57% vs. 49%), endoscopy-related morbidity (6% vs. 7%) and CTC-related morbidity (0 vs. 1%). Most patients (64%) underwent endoscopy, which was more common in the borderline vs. the diminutive group (76% vs. 59%; P = 0.003). Dysplasia was more common in the borderline vs. the diminutive group (69% vs. 48%; P = 0.003). No malignancies were diagnosed, and no patients proceeded to surgery. Conclusion: Reporting diminutive polyps on CTC for symptomatic patients frequently leads to endoscopy, which often reveals dysplasia but rarely malignancy. This raises the question of how referring clinicians can best counsel and manage symptomatic patients with diminutive polyps on CTC, by considering the balance between utilitarianism and deontology.
• Impact of minimally invasive surgery on surgeon health (ISSUE) study: protocol of a single-arm observational study conducted in the live surgery setting

  Singh, Baljit; Moss, Esther (2023-03-07)

  Introduction: The rapid evolution of minimally invasive surgery has had a positive impact on patient outcomes; however, it is reported to be associated with work-related musculoskeletal symptoms (WMS) in surgeons. Currently there is no objective measure to monitor the physical and psychological impact of performing a live surgical procedure on the surgeon. Methods and analysis: A single-arm observational study with the aim of developing a validated assessment tool to quantify the impact of surgery (open/laparoscopic/robotic-assisted) on the surgeon. Development and validation cohorts of major surgical cases of varying levels of complexity performed by consultant gynaecological and colorectal surgeons will be recruited. Recruited surgeons wear three Xsens DOT monitors (muscle activity) and an Actiheart monitor (heart rate). Salivary cortisol levels will be taken and questionnaires (WMS and State-Trait Anxiety Inventory) completed by the participants preoperatively and postoperatively. All the measures will be incorporated to produce a single score that will be called the 'S-IMPACT' score. Ethics and dissemination: Ethical approval for this study has been granted by the East Midlands Leicester Central Research Ethics Committee REC ref 21/EM/0174. Results will be disseminated to the academic community through conference presentations and peer-reviewed journal publications. The S-IMPACT score developed within this study will be taken forward for use in definitive multicentre prospective randomised control trials.
• Inequalities in cancer mortality trends in people with type 2 diabetes: 20 year population-based study in England

  Zaccardi, Francesco; Issa, Eyad; Davies, Melanie; Khunti, Kamlesh; Brown, Karen (2023-01-24)

  Aims/hypothesis: The aim of this study was to describe the long-term trends in cancer mortality rates in people with type 2 diabetes based on subgroups defined by sociodemographic characteristics and risk factors. Methods: We defined a cohort of individuals aged ≥35 years who had newly diagnosed type 2 diabetes in the Clinical Practice Research Datalink between 1 January 1998 and 30 November 2018. We assessed trends in all-cause, all-cancer and cancer-specific mortality rates by age, gender, ethnicity, socioeconomic status, obesity and smoking status. We used Poisson regression to calculate age- and calendar year-specific mortality rates and Joinpoint regression to assess trends for each outcome. We estimated standardised mortality ratios comparing mortality rates in people with type 2 diabetes with those in the general population. Results: Among 137,804 individuals, during a median follow-up of 8.4 years, all-cause mortality rates decreased at all ages between 1998 and 2018; cancer mortality rates also decreased for 55- and 65-year-olds but increased for 75- and 85-year-olds, with average annual percentage changes (AAPCs) of -1.4% (95% CI -1.5, -1.3), -0.2% (-0.3, -0.1), 1.2% (0.8, 1.6) and 1.6% (1.5, 1.7), respectively. Higher AAPCs were observed in women than men (1.5% vs 0.5%), in the least deprived than the most deprived (1.5% vs 1.0%) and in people with morbid obesity than those with normal body weight (5.8% vs 0.7%), although all these stratified subgroups showed upward trends in cancer mortality rates. Increasing cancer mortality rates were also observed in people of White ethnicity and former/current smokers, but downward trends were observed in other ethnic groups and non-smokers. These results have led to persistent inequalities by gender and deprivation but widening disparities by smoking status. Constant upward trends in mortality rates were also observed for pancreatic, liver and lung cancer at all ages, colorectal cancer at most ages, breast cancer at younger ages, and prostate and endometrial cancer at older ages. Compared with the general population, people with type 2 diabetes had a more than 1.5-fold increased risk of colorectal, pancreatic, liver and endometrial cancer mortality during the whole study period. Conclusions/interpretation: In contrast to the declines in all-cause mortality rates at all ages, the cancer burden has increased in older people with type 2 diabetes, especially for colorectal, pancreatic, liver and endometrial cancer. Tailored cancer prevention and early detection strategies are needed to address persistent inequalities in the older population, the most deprived and smokers.
• A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation

  Garcea, Giuseppe; Popa, Mariuca (2022-10-06)

  Purpose: A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort. Methods: An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included. Results: A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%. Conclusion: Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.
• Significance of thickening of the upper gastrointestinal tract on cross sectional imaging: Endoscopic correlation

  Hunter, David; Kenningham, Richard; Billimoria, Vini; Bowrey, David (2022-06-03)

  Aim: To report the endoscopic findings for a cohort of patients referred for discussion at a specialist oesophago-gastric multi-disciplinary team (MDT) meeting, on the basis of CT mural thickening. Patients and methods: The records of patients discussed at a regional oesophago-gastric MDT during the time 1st April 2014 to 5th February 2016 were reviewed in order to identify patients who were endoscopy naïve at the time of CT and scans re-reviewed to measure maximum wall thickness. Results: 456 patients were referred for discussion, 126 met the inclusion criteria. Endoscopy confirmed malignancy in 50/126 patients (40%); by site, oesophagus (21/67, 31%), stomach (25/50, 50%), duodenum (4/9, 44%). Malignancy was confirmed for 10/48 (21%) patients with isolated wall thickening, for 11/33 (33%) when regional lymphadenopathy was identified, and for 28/44 (64%) when possible metastatic disease was identified. The commonest source of diagnostic uncertainty was thickening around the gastro-oesophageal junction in the presence of a hiatal hernia. Wall thickening >20 mm was strongly associated with malignancy compared to thickening =<20 mm (p < 0.0001). Using this threshold would have resulted in a sensitivity of 32/50 (64%), a specificity of 55/76 (72%), a positive predictive value of 32/53 (60%) and a negative predictive value of 55/73 (75%) in this cohort. Conclusions: The cancer pick-up rate of 40% and the medicolegal consequences of a missed cancer suggest that endoscopy should be performed in all patients with CT identified mural thickening. In the presence of isolated mural thickening and a normal endoscopy, no formal MDT discussion is required.
• JAG consensus statements for training and certification in oesophagogastroduodenoscopy

  Williams, R N (2022-01-24)

  Introduction: Training and quality assurance in oesophagogastroduodenoscopy (OGD) is important to ensure competent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for OGD training and certification. Methods: Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted with stakeholder representation from British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on OGD training and certification were formulated following literature review and appraised using Grading of Recommendations Assessment, Development and Evaluation. These were subjected to electronic voting to achieve consensus. Accepted statements were incorporated into the updated certification pathway. Results: In total, 32 recommendation statements were generated for the following domains: definition of competence (4 statements), acquisition of competence (12 statements), assessment of competence (10 statements) and post-certification support (6 statements). The consensus process led to following certification criteria: (1) performing ≥250 hands-on procedures; (2) attending a JAG-accredited basic skills course; (3) attainment of relevant minimal performance standards defined by British Society of Gastroenterology/Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, (4) achieving physically unassisted D2 intubation and J-manoeuvre in ≥95% of recent procedures, (5) satisfactory performance in formative and summative direct observation of procedural skills assessments. Conclusion: The JAG standards for diagnostic OGD have been updated following evidence-based consensus. These standards are intended to support training, improve competency assessment to uphold standards of practice and provide support to the newly-independent practitioner.
• Management and outcomes of traumatic pediatric spinal cord injuries in low- and middle-income countries: A scoping review

  Kotecha, Jay (2022-06-20)

  Background: Traumatic spinal cord injury (TSCI) is a subset of neurotrauma, which is a significant contributor to global trauma mortality and morbidity in children. The management and outcomes of pediatric TSCI in low- and middle-income countries (LMICs) is unknown. We conducted a scoping review to characterize the methods of management and outcomes of TSCI in LMICs. Methods: MEDLINE, Embase, and Global Index Medicus were searched from database inception to February 15, 2021. Studies reporting management or outcomes of pediatric TSCI in LMICs were included. Pooled statistics were calculated using measures of central tendency and spread. Results: A total of 1171 studies were identified, of which 5 were included. A total of 212 patients were included in our review with age of participants ranging from 2.5 to 18 years (mean, 15.4 years). Most patients were male (n = 162; 76.4%). The commonest cited cause of injury were falls (n = 104/212; 49.1%). The most common level of injury was cervical (n = 83; 39.2%). Most patients underwent surgery (n = 134/212; 63.2%). The extent of injury was quantified and classified using the American Spinal Injury Association chart in only 1 study. Long-term management data were not present in any of the included studies. Conclusions: There is a scarcity of studies reporting the management and outcome of pediatric TSCI in LMICs. The paucity of studies in this domain provides insufficient data to be compared, reducing the ability to draw a strong conclusion. This situation hinders the development of guidelines to inform best practice.
• Impact of COVID-19, gender, race, specialty and seniority on mental health during surgical training: an international study

  Layton, Georgia; Issa, Eyad; Dennison, Ashley (2022-08-18)

  Background: Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross-sectional study determining relative impacts of COVID-19, gender, race, specialty and seniority on mental health of surgical trainees. Method: Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire-2 and the effect on individual stress levels of training experiences affected by COVID-19. Predictors included trainee characteristics and local COVID-19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors. Results: Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID-19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID-19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P < 0.0001). Greater depression was associated with more seniority (P < 0.0001). Greater COVID-19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P < 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002). Conclusion: This is the first study to specifically describe the relative impacts of COVID-19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale.
• A meta-analysis: incidental intraductal papillary mucinous neoplasm and extra-pancreatic malignancy

  Fraser, Rebecca; Garcea, Giuseppe (2021-10-19)

  Introduction: Meta-analysis aimed to quantify the relationship between intraductal papillary mucinous neoplasm (IPMN) and increased incidence of extra-pancreatic malignancy (EPM) previously reported in qualitative observational cohort studies. Methods: Study protocol was registered with PROSPERO (CRD42020169614) and conducted to the Meta-analysis Of Observational Studies in Epidemiology and systematic review reported with Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Assessing the Methodological Quality of Systematic Reviews guidelines. Results: Sixteen studies (total of 8240 patients) were included in the pooled, and 7399 patients in the subgroup meta-analyses. The odds ratio (OR) for any EPM in the presence of IPMN was 57.9 (95% confidence interval 40.5-82.7), fixed effects, I2 = 59% (p < 0.0014). Subgroup analysis for any gastrointestinal EPM (i.e. oesophagus, stomach, colon and rectum) in the presence of an IPMN estimated an overall OR of 12.9 (95% confidence interval 8.8-19.0), fixed effects, I2 = 64% (p < 0.0004). Conclusion: Patients with an IPMN are categorically at increased risk for a higher incidence of EPM and particularly the odds of a gastrointestinal malignancy are also increased in comparison with the general population. We advocate that patients presenting with an IPMN should be considered for gastrointestinal screening including colonoscopy, upper gastrointestinal endoscopy or computed tomography.
• Splenic macrophages as the source of bacteraemia during pneumococcal pneumonia

  Chung, Wen Yuan; Dennison, Ashley (2021-10-04)

  Background: Severe community-acquired pneumococcal pneumonia is commonly associated with bacteraemia. Although it is assumed that the bacteraemia solely derives from pneumococci entering the blood from the lungs it is unknown if other organs are important in the pathogenesis of bacteraemia. Using three models, we tested the relevance of the spleen in pneumonia-associated bacteraemia. Methods: We used human spleens perfused ex vivo to explore permissiveness to bacterial replication, a non-human primate model to check for splenic involvement during pneumonia and a mouse pneumonia-bacteraemia model to demonstrate that splenic involvement correlates with invasive disease. Findings: Here we present evidence that the spleen is the reservoir of bacteraemia during pneumonia. We found that in the human spleen infected with pneumococci, clusters with increasing number of bacteria were detectable within macrophages. These clusters also were detected in non-human primates. When intranasally infected mice were treated with a non-therapeutic dose of azithromycin, which had no effect on pneumonia but concentrated inside splenic macrophages, bacteria were absent from the spleen and blood and importantly mice had no signs of disease. Interpretation: We conclude that the bacterial load in the spleen, and not lung, correlates with the occurrence of bacteraemia. This supports the hypothesis that the spleen, and not the lungs, is the major source of bacteria during systemic infection associated with pneumococcal pneumonia; a finding that provides a mechanistic basis for using combination therapies including macrolides in the treatment of severe community-acquired pneumococcal pneumonia. Funding: Oxford University, Wolfson Foundation, MRC, NIH, NIHR, and MRC and BBSRC studentships supported the work.
• Outcomes of peri-operative glucocorticosteroid use in major pancreatic resections: a systematic review

  Dennison, Ashley; Garcea, Giuseppe

  Background: There is increasing evidence that peri-operative glucocorticosteroid can ameliorate the systemic response following major surgery. Preliminary evidence suggests peri-operative usage of glucocorticosteroid may decrease post-operative complications. These positive associations have been observed in a range of different operations including intra-abdominal, thoracic, cardiac, and orthopaedic surgery. This review aims to investigate the impact of peri-operative glucocorticosteroid in major pancreatic resections. Methods: A systematic review based on a search in Medline and Embase databases was performed. PRISMA guidelines for systematic reviews were followed. Results: A total of five studies were analysed; three randomised controlled trials and two retrospective cohort studies. The total patient population was 1042. The glucocorticosteroids used were intravenous hydrocortisone or dexamethasone. Three studies reported significantly lower morbidity in the peri-operative glucocorticosteroid group. The number needed to treat to prevent one major complication with hydrocortisone is four patients. Two studies demonstrated that dexamethasone was associated with a statistically significantly improved median overall survival in pancreatic cancer. Conclusion: This is the first systematic review conducted to investigate the significance of peri-operative glucocorticosteroid in patients undergoing pancreatic resection. This review shows a correlation of positive outcomes with the administration of glucocorticosteroid in the peri-operative setting following a major pancreatic resection.. More randomised clinical trials are required to confirm if this is a true effect, as it would have significant implications.
• A multi-centre study to risk stratify colorectal polyp surveillance patients utilising volatile organic compounds and faecal immunochemical test

  Khasawneh, Farah; Singh, Baljit (2022-10-09)

  Background: The service capacity for colonoscopy remains constrained, and while efforts are being made to recover elective services, polyp surveillance remains a challenge. (2) Methods: This is a multi-centre study recruiting patients already on polyp surveillance. Stool and urine samples were collected for the faecal immunochemical test (FIT) and volatile organic compounds (VOC) analysis, and all participants then underwent surveillance colonoscopy. (3) Results: The sensitivity and specificity of VOC for the detection of a high-risk finding ((≥2 premalignant polyps including ≥1 advanced polyp or ≥5 premalignant polyps) were 0.94 (95% CI, 0.88 to 0.98) and 0.69 (95% CI, 0.64 to 0.75) respectively. For FIT, the sensitivity was (≥10 µg of haemoglobin (Hb) / g faeces) 0.54 (95% CI, 0.43 to 0.65) and the specificity was 0.79 (95% CI, 0.73 to 0.84). The probability reduction for having a high-risk finding following both negative VOC and FIT will be 24% if both tests are applied sequentially. (4) Conclusion: The diagnostic performance of VOC is superior to FIT for the detection of a high-risk finding. The performance further improves when VOC is applied together with FIT sequentially (VOC first and then FIT). VOC alone or the combination of VOC and FIT can be used as a triage tool for patients awaiting colonoscopy within a polyp surveillance population, especially in resource-constrained healthcare systems.
• One-year follow-up of conservative management of appendicitis: results from a single centre during extended lockdown in the COVID-19 pandemic

  West, H; Garcea, Giuseppe

  Introduction: Conservative management with antibiotics was recommended by the UK Surgical Royal Colleges early in the COVID-19 pandemic as the first-line treatment for acute uncomplicated appendicitis. Methods: This is a prospective single-centre cohort study of patients aged 16 years or over, diagnosed clinically and confirmed radiologically with acute appendicitis in a secondary care setting who were initially treated conservatively with antibiotics. The primary outcome was the response to conservative management with antibiotics. Secondary outcomes were: antibiotic duration; operative rates; surgical approach (open, laparoscopic or conversion to open); complication rates; COVID-19 positive rate; rates of readmission within 12 months; and length of hospital stay. Results: A total of 109 patients were included in the study, 67 of whom were male. Median age was 37 (range 17-93) years. A further 28 patients were excluded because of a decision to manage operatively on the index admission or because of other diagnoses. Thirty-three patients (30.3%) had surgery on the index admission after failed conservative management and 15 (13.8%) had surgery on readmission. On histology, 32/48 patients (66.7%) had a diagnosis of complicated appendicitis and 18/48 (37.5%) had a confirmed appendicolith. Conclusions: There was a high readmission rate (47/109; 43.1%) for surgery, a radiological drain or conservative management within the first year following initial conservative management. There is a significant risk of recurrence of symptoms, particularly in the presence of an appendicolith. Laparoscopic appendicectomy should be the first-line treatment, with conservative management reserved for patients with acute uncomplicated appendicitis who are COVID-19 positive or have comorbidities.

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