Gastric Research Articles

Impact of glucagon-Like peptide-1 agonists in optimizing abdominal wall Reconstruction patients.

Pre-optimization of obese patients prior to abdominal wall reconstruction (AWR) is essential in mitigating their increased preoperative risks. Traditionally diet, exercising, bariatric surgery are the tools typically prescribed for weight loss. The advent of glucagon-like peptide-1 agonists (GLP-1A) which stimulate insulin secretion and inhibit gastric emptying have improved the weight loss armamentarium. However, there is a limited amount of literature on GLP-1A effectiveness and postoperative outcomes in AWR patients. This study compares the efficacy of GLP-1A to Bariatric Surgery (BAS) in perioperative AWR patient. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2021 and March 2024. We included patients who required GLP-1A or BAS for weight optimization prior to AWR. We excluded patients on GLP1-A or history BAS not performed for AWR preoptimization. Basic demographics such as age, sex, race, weight and BMI at initial clinic visit and at surgery were compared. Primary endpoints included time to surgery, time to bowel recovery and length of stay (LOS). Time to surgery was defined as the number of months between the initial clinic visit and AWR. Time to bowel recovery was defined as the number of days it took for the first postoperative bowel function. Secondary endpoints included standard 30-days postoperative variables. Nominal variables were analyzed using a Fisher exact test and continuous variables were analyzed with Student's T test. 35 patients were included in this study (GLP-1A: 17, BAS: 18). The GLP-1A cohort had a lesser BMI at the initial clinic visit (40.8 vs 43.4, p = 0.188). GLP-1A cohort made it to the operating room faster (9.1 months vs 13.5 months, p = 0.06) from the first clinic visit; and (7.9 months vs 9.7 months, p = 0.4) from initiation of weight loss intervention. Albeit losing less weight (14.9 kg vs 27.1 kg, p = 0.008) with a lesser reduction in the BMI (4.69 vs 9.23, p = 0.004). The GLP-1A cohort showed a non-significant elevated LOS (5.2 days vs 3.6 days, p = 0.25) and an increased ileus rate (17.6% vs 0%, p = 0.1). However, there were no differences noted in time to bowel recovery (2.9 days vs 3.1 days, p = 0.76). GLP-1A is effective in optimizing patients needing weight loss before AWR. They shorten the timeline to AWR intervention and have comparable peri-operative outcomes to BAS patients.

Treatment of choice for malignant gastric outlet obstruction: More than clearing the road

In this editorial, we comment on the in-press article in the World Journal of Gastrointestinal Endoscopy concerning the treatment of malignant gastric outlet obstruction (mGOO). The original theory of treatment involves bypassing the obstruction or reenabling the patency of the passage. Conventional surgical gastroenterostomy provides long-term relief of symptoms in selected patients, with substantial morbidity and a considerable rate of delayed gastric emptying. Endoscopic stenting was introduced as an alternative minimally invasive procedure with less procedural morbidity and rapid clinical improvement; however, it presented a high rate of long-term recurrence. Therefore, challenges remain in the treatment of mGOO patients to improve clinical outcomes. Endoscopic ultrasound-guided gastroenterostomy has recently emerged as a promising method because of the combined effects of surgery and endoscopy, whereas stomach-partitioning gastrojejunostomy has been reported as a modified surgical procedure to reduce the rate of delayed gastric emptying. In decision-making regarding the treatment of choice, it should be taken into account that mGOO might be accompanied by a variety of pathological conditions, including cancer cachexia, anorexia, malabsorption, and etc. , all of which can also lead to the characteristic symptoms and poor nutritional status of mGOO. The treatment plan should consider comprehensive aspects of patients to achieve practical improvements in prognosis and the quality of life.

Impact of L-carnitine supplementation on gastric emptying and bowel function in pediatric ketogenic diet therapy: a clinical trial.

Ketogenic diet (KD) is an excess fat, enough protein, and minimal carbohydrate diet. The high fat content in KD lowers the oesophageal sphincter tone, slows gastric emptying, and decreases intestinal transit time. The primary aim of the current clinical trial was to study the effect of L-carnitine supplementation on gastric emptying in children with drug resistant epilepsy (DRE) on KD. Assessment of the protective effect of L-carnitine on bowel function and habits in those patients was a secondary aim. The current study recruited 30 patients aged 12 months to 18 years newly diagnosed with DRE assigned to start KD who were following up at the Pediatric Clinical Nutrition and Neurology Outpatient Clinics or were admitted due to DRE at the Pediatric Neurology Inpatient Department, Children's Hospital, Ain Shams University (Egypt). Participants were assigned randomly into 2 arms; arm I: received KD with L-carnitine supplementation, arm II: received KD only. Patients were assessed at baseline and after 3 months of starting KD, the assessments of children included: 24-hour dietary recall, Chalfont Seizures Severity Scale, gastrointestinal symptoms score and Bristol stool chart, frequency of defecation per week, anthropometric measurements assessment, fasting serum lipid profile and measurement of the antral length by ultrasound. There was significant increase in antral length in the patients who received KD with L-carnitine supplementation compared to the non-supplemented group. The antral length showed a significant negative correlation with GI symptoms score in all cases and the L-carnitine supplemented group. It also showed a significant positive correlation with Bristol stool score in all patients and a significant positive correlation with stool frequency in the L-carnitine supplemented group only. L-carnitine supplementation to children with DRE on KD has a significant role in improving gastric motility and it increases the frequency of defecation. Further studies are recommended to explore additional benefits, meanwhile it is prudent to advise L-carnitine supplementation for such patients.

Perioperative Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RA) and Gastric Point Of Care Ultrasound (POCUS)

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are frequently used for diabetes and weight loss management. The GLP-1 RA drugs delay gastric emptying and are a concern for increased risk of aspiration in the perioperative period. Current recommendations to hold these medications before surgery are consensus based. Gastric point of care ultrasound (POCUS) can provide information regarding nature and volume of gastric contents in these patients during the perioperative period. In this case series, we present three patients where gastric POCUS helped formulate a safer, alternative anesthetic plan. Anesthetic management varied depending on the situation, urgency and needs of the procedure. We recommend gastric POCUS in this group of patients to provide objective assessment of gastric contents.

Adjuvant chemoradiotherapy plus PD-1 inhibitor for pN3 gastric cancer: a randomized, multicenter, Phase III trial.

D2 surgery followed by adjuvant chemotherapy has been established as the standard of care for patients with locally advanced gastric cancer in Asian countries. However, its efficacy is still unsatisfactory, especially for pathological N3 disease. The RACING trial is a randomized, multicenter, Phase III trial designed to compare the efficacy and safety of chemotherapy alone versus chemotherapy in combination with PD-1 inhibitor and radiotherapy in patients with pN3 gastric or gastroesophageal junction adenocarcinoma. A total of 433 patients will be assigned at a 1:1 ratio to the two arms. The primary end point is the 3-year disease-free survival rate. The secondary end points include the 3-year overall survival rate, 3-year local recurrence-free survival rate, treatment-related adverse events and quality of life.Clinical Trial Registration: NCT04997837 (ClinicalTrials.gov).

Increased gallbladder emptying and reduced GLP-1 response in pregnancy with and without gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) has been associated with reduced postprandial glucagon-like peptide 1 (GLP-1) responses. As pregnancy induces changes in gallbladder motility and bile acids stimulate GLP-1 secretion, we investigated postprandial gallbladder emptying and GLP-1 responses in women with GDM. Women with and without GDM underwent two 240-min mixed meal tests; one during third trimester of pregnancy and one 3-6 months postpartum. We evaluated ultrasonography-assessed gallbladder emptying, plasma concentrations of glucometabolic hormones including GLP-1, paracetamol absorption (proxy for gastric emptying) and circulating factors known to affect gallbladder dynamics. Fifteen women with GDM and 15 pregnant women with normal glucose tolerance (NGT) (baseline median age 31 (interquartile range 29;33) versus 32 (28;33) years, body mass index (BMI) 27.2 (24.7;30.7) versus 28.4 (26.2;31.0) kg/m2, HbA1c 30 (29;32) versus 30 (28;31) mmol/mol) were included. No differences in postprandial gallbladder emptying or GLP-1 responses were observed between women with and without GDM, neither during pregnancy nor postpartum. Pregnancy increased fasting gallbladder volumes by 69 (30;122)% and 103 (59;156)% and postprandial gallbladder emptying by 77 (28;236)% and 99 (37;190)% compared with postpartum in women with and without GDM, respectively. Postprandial GLP-1 responses were reduced by 60 (3;82)% and 81 (11;90)% during pregnancy compared with postpartum in women with and without GDM, respectively. Pregnancy-induced changes in gallbladder motility seem to play no or a limited role in previously reported GDM-associated reduced postprandial GLP-1 responses as gallbladder emptying was greater and postprandial GLP-1 response was lower in pregnancy than postpartum regardless of GDM status.

An additional gastrojejunostomy may reduce the incidence of moderate and severe delayed gastric emptying after distal segmental duodenectomy for gastrointestinal stromal tumors.

To investigate whether an additional gastrojejunostomy reduces the incidence of delayed gastric emptying (DGE) following a distal segmental duodenectomy for duodenal and proximal jejunal gastrointestinal stromal tumors (GIST). This retrospective review of the GIST database at Peking University Cancer Hospital included 50 patients who underwent distal segmental duodenectomies for primary GIST in the duodenum or proximal jejunum within 20cm of Treitz's ligament between January 2008 and December 2023. The patients were divided into two groups: non-bypass (without gastrojejunostomy) and bypass (with gastrojejunostomy and Braun's jejunojejunostomy). Perioperative characteristics and postoperative complications were analyzed. Among the 50 patients, 27 underwent duodenojejunostomies without gastrojejunostomies and 23 with gastrojejunostomies and Braun's jejunojejunostomies. The incidence of grade B-C DGE was significantly lower in the bypass group (43.5% vs. 74.1%, p = 0.028). In addition, non-bypass surgery was an independent risk factor for increased grade B-C DGE (OR 3.67, 95% CI 1.07-12.64, p = 0.039). The bypass group showed a trend towards a shorter postoperative hospital stay (median: 14 days, range: 10-56) compared to the non-bypass group (median: 28 days, range: 6-75), but this difference did not reach statistical significance (p = 0.070). Operative time (min) was significantly longer in the multi-visceral resection group (381.0 ± 108.8 vs. 227.3 ± 87.6, p < 0.001), for tumors ≥ 6.3cm compared to < 6.3cm (337.0 ± 116.4 vs. 228.3 ± 99.8, p = 0.002), and in patients with positive preoperative symptoms versus asymptomatic patients (319.9 ± 118.0 vs. 210.2 ± 90.3, p = 0.031). The addition of gastrojejunostomy and Braun's jejunojejunostomy in distal segmental duodenectomy can reduce the incidence of grade B-C DGE, potentially facilitating timely adjuvant imatinib therapy. Future multicenter studies are needed to confirm these findings.

Predictors of outcomes after gastric peroral endoscopic myotomy for refractory gastroparesis: a systematic review

Background: Gastroparesis is a debilitating gastroduodenal disorder for which gastric peroral endoscopic myotomy (GPOEM) has emerged as an efficacious treatment option. However, response to GPOEM varies between 50-80%, such that preoperative predictors of treatment success are needed to guide patient selection. Methods: We performed a systematic review to identify predictors of clinical and functional response to GPOEM among adult patients with gastroparesis (PROSPERO: CRD42023457359). MEDLINE, Embase, and CENTRAL databases were searched systematically for studies reporting outcomes after GPOEM in September 2023. A narrative synthesis of predictive factors on univariable and multivariable analysis was performed with consideration of response rates via meta-analysis, and evaluation of discrimination if prognostic models were developed. ROBINS-E was used for risk of bias assessment. Results: Of 1899 articles reviewed, 30 were included. The GPOEM response rate was 63.1% (95% confidence interval 56.3%-69.5%) with most studies defining clinical success on the basis of improvement in gastroparesis cardinal symptom index (87%, 26/30). Older age, shorter duration of gastroparesis, non-diabetic etiology, lower body mass index, and response to intrapyloric botulinum toxin were associated with positive response to GPOEM on multivariable analyses. Predictors on physiological tests such as EndoFLIP or gastric emptying scintigraphy were inconsistent. No prognostic models underwent external validation. Conclusion: Currently, there are limited reproducible predictors of response to GPOEM among patients with refractory gastroparesis. Robust prospective studies investigating scalable, reproducible, and actionable biomarkers of treatment response are required.

Erectile Dysfunction Therapy of Bariatric Patients: Tadalafil Biopharmaceutics and Pharmacokinetics Before vs. After Gastric Sleeve/Bypass.

Bariatric surgery introduces significant changes in the gastrointestinal tract, which may affect oral drug absorption/bioavailability. Here we investigate the phosphodiesterase-5 inhibitor (PDE5i) tadalafil for potentially impaired post-bariatric solubility/dissolution and absorption. Solubility was studied in vitro in different pHs, and ex vivoin gastric content aspirated from patients pre/post-surgery. Dissolution was studied in conditions mimicking pre/post-surgery stomach. Finally, the experimental data were used in physiologically-based pharmacokinetic (PBPK) model (GastroPlus®) to simulate pre- vs. post-surgery tadalafil PK. Tadalafil demonstrated low and pH-independent solubility, both in vitro and ex vivo. Tadalafil release from all drug products and under all gastric conditions was incomplete, with particularly poor dissolution (2%) of the highest dose under post-bariatric conditions. PBPK simulations revealed altered tadalafil PK after gastric bypass-but not after sleeve gastrectomy-compared to unoperated individuals, with 44-48% decreased Cmax, 35-56% decreased AUC and 44% shorter Tmax. This mechanistic analysis suggests that tadalafil may be as effective after sleeve gastrectomy as before the procedure; meanwhile, results after gastric bypass raise concerns regarding the bioperformance of the drug. In addition, the drug's duration of action may be much shorter after gastric bypass. Thus, the effectiveness of tadalafil, widely regarded as the 'weekend pill', may be shorter than expected among gastric bypass patients.

The Inhibitory Effect of Hedera helix and Coptidis Rhizome Mixture in the Pathogenesis of Laryngopharyngeal Reflux: Cleavage of E-Cadherin in Acid-Exposed Primary Human Pharyngeal Epithelial Cells

Laryngopharyngeal reflux disease (LPRD) is a prevalent upper airway disorder characterized by inflammation and epithelial damage due to the backflow of gastric contents. Current treatments, primarily proton pump inhibitors (PPIs), often show variable efficacy, necessitating the exploration of alternative or adjunctive therapies. This study investigates the therapeutic potential of a mixture of Hedera helix and Coptidis rhizome (HHCR) in mitigating the pathophysiological mechanisms of LPRD. Using an in vitro model of human pharyngeal epithelial cells exposed to acidic conditions, we observed that acid exposure significantly increased the expression of adenosine A3 receptor (adenosine A3) and matrix metalloproteinase-7 (MMP-7), leading to E-cadherin cleavage and compromised epithelial integrity. Treatment with the HHCR mixture effectively suppressed adenosine A3 expression and MMP-7 activity, thereby reducing E-cadherin cleavage and preserving cellular cohesion. These results highlight the HHCR mixture’s ability to modulate the adenosine A3–MMP-7–E-cadherin pathway, suggesting its potential as a valuable adjunctive therapy for LPRD, particularly for patients unresponsive to conventional PPI treatment. This study provides new insights into the molecular interactions involved in LPRD and supports further clinical evaluation of HHCR as a complementary treatment option.

Abstract A041: Detection of early-stage gastrointestinal cancers using micronuclei DNA from erythrocytes

Abstract Background: Gastrointestinal (GI) cancers account for over a third of cancer deaths. However, their early detection remains a challenge. Micronuclei (MN) are cytoplasm-resident subcellular structures, containing damaged chromosome segments that indicative of genomic instability. Increased MN frequency in hematopoietic cells is observed in patients with solid tumors. Our developed technique (WO2021/228246 A1) enables the purification and characterization of micronuclei DNA in erythrocytes from peripheral blood. By comparing MN-DNA from healthy donors (HDs) and GI cancer patients, we identified significant changes in read densities at specific genomic locations in patients, which were termed as tumor-associated MN-DNA (taMN- DNA) features. Here, we evaluated the potential of these features for early-stage GI cancer detection, including colorectal (CC), gastric (GC) and esophageal (EC) cancers. Methods: Peripheral blood (1-2 mL) was collected from healthy donors (HD) and cancer patients MN-DNA isolation and purification from erythrocytes. Participants were randomly divided into training, validation and independent test cohorts in a 7:2:1 ratio, maintaining similar cancer types, gender and age distribution. Distinct MN-DNA features between cancer patients and HDs were identified using sequencing data. Machine learning algorithms were applied using these features for cancer detection. Results: The study enrolled 1753 participants, including 987 HDs, 420 CC, 282 GC and 64 EC cases. Of these, over half were diagnosed with early-stage diseases; TNM stage 0-I accounted for 40.57%, stage II for 23.32%, stage III for 29.25% and stage IV for 6.87%. The pan-cancer model achieved 88.2% sensitivity with an overall specificity of 95.4%. Patients in individual caner types were detected from the tissue of origin classification with an overall accuracy of 91.9% based on pan-cancer at 95.4% specificity. Sensitivity was 90.8% for CC, 91.7% for GC and 100% for EC. For early- stage (stage 0-II) CC, GC and EC, the model demonstrated sensitivities of 97.4%, 94.7% and 100.00%, respectively, at 95.4% specificity. Conclusions: Unlike cell-free DNA, MN-DNA are chromosomal fragments in the cytoplasm. The abundance of erythrocytes in peripheral blood provides an easily accessible source for MN-DNA enrichment. This pilot study illustrates the potential of MN-DNA as a tool for early GI cancer detection, contributing to large-scale efforts towards developing an effective GI cancer screening test. Research sponsor: Timing Biotech. Citation Format: Haobo Sun, Xingyun Yao, Yuehua Han, Yurong Jiao, Xiangxing Kong, Chengcheng Liu, Qingqu Guo, Fei Meng, Honghao Liang, Hongbo Li, Xiuqin Fan, Jun Li, Xiaofei Gao. Detection of early-stage gastrointestinal cancers using micronuclei DNA from erythrocytes [abstract]. In: Proceedings of the AACR Special Conference: Liquid Biopsy: From Discovery to Clinical Implementation; 2024 Nov 13-16; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(21_Suppl):Abstract nr A041.

OGC SO13 - Recurrence Patterns after Minimally Invasive vs. Left Thoracoabdominal Oesophagectomy for distal oesophageal and junctional adenocarcinomas

Abstract Background Oesophageal cancer is a leading cause of cancer-related death worldwide, with oesophagec-tomy being the primary treatment for curable disease. This study compares loco-regional and distal disease recurrence patterns between minimally invasive oesophagectomy (MIO) and left thoracoabdominal oesophagectomy (LTAO) using a matched dataset. The definition of loco-regional recurrence remains unclear in the literature. In this study, loco-regional recur-rence is categorised as recurrence in the oesophageal bed, anastomosis, or local nodes in the mediastinum and upper abdomen. Method Patients from 2014 to 2021 were identified and followed until 31/12/2023. Data on MIOs and LTAO were collected from a prospectively maintained database. Gastroesophageal junction and distal oesophagus adenocarcinomas were included, and all received neoadjuvant chemotherapy. Out of 302 eligible patients, 104 were successfully matched. The primary outcome was overall cancer recurrence. Categorical variables were compared using chi-square tests, and non-parametric contin-uous variables with Mann-Whitney U tests. Propensity score matching, accounted for baseline differences. Logistic regression generated propensity scores for age, gender, and tumour stage. Operative approach was the dependant variable. The groups were then selected using ‘nearest neighbour’ matching. Results The study compared 52 cases each of LTAO and MIO. Postoperative complications were similar, LTAO (58%) and MIO (52%) P=0.554. The R0 resection rate was higher in LTAO (90%) compared to MIO (81%) P=0.163. Recurrence was significantly higher in LTAO (42%) than MIO (23%) P=0.037. Local recurrence rates were 15% for LTAO and 8% for MIO P=0.22. Distant recurrence was 35% for LTAO and 21% for MIO P=0.111. Notably, peritoneal recurrence was significantly higher in LTAO (12%) P=0.012. There was no difference in median time to recurrence. Mortality rate was similar: 38% for LTAO and 35% for MIO P=0.684. Conclusion The study found that while postoperative complications and mortality rates were similar between LTAO and MIO, LTAO had a significantly higher overall recurrence rate and notably higher peritoneal recurrence. There was no significant difference in median time to recurrence between the two groups. These findings suggest that MIO may be associated with better long-term outcomes in terms of recurrence.

SOX combined with tislelizumab and low-dose radiation therapy for the neoadjuvant treatment of locally advanced gastric/gastroesophageal junction adenocarcinoma: study protocol for a prospective, multicenter, single-arm, phase Ib/II clinical trial

BackgroundRecently, the clinical benefits of neoadjuvant chemotherapy combined with immunotherapy have been observed in patients with locally advanced gastric or gastroesophageal junction (G/GEJ) cancer; however, the pathological complete response (pCR) and long-term survival rates are still unsatisfactory. The aim of this study is to investigate the efficacy and safety of chemotherapy combined with tislelizumab and low-dose radiation therapy (LDRT) for the neoadjuvant treatment of locally advanced G/GEJ cancer.MethodsThis is a prospective, multicenter, single-arm, phase Ib/II trial. In the phase Ib study, 5 patients will be enrolled in each treatment group with different radiation doses. In the phase II study, a total of 44 patients will be enrolled. Eligible patients will be registered and receive three cycles of SOX regimen chemotherapy (S-1: 40-60 mg Bid, d1-14, q3w; oxaliplatin: 130 mg/m2, iv drip, d1, q3w) plus tislelizumab (200 mg, iv drip, d1, q3w). Simultaneously, LDRT will be planned and administered after the first cycle of systemic therapy. Radical D2 gastrectomy will be performed 4-6 weeks after the last administration of chemotherapy plus tislelizumab. The primary endpoint of phase Ib study is to determine the optimal radiation dose for phase II study. The primary endpoint of phase II is the pCR rate. The secondary endpoints include R0 resection rate, major pathological response (MPR) rate, 2-year event-free survival (EFS) rate, 2-year overall survival (OS) rate and safety profile. Moreover, we will also explore potential molecular markers for predicting the benefit and safety of this neoadjuvant regimen. Written informed consent should be provided by all patients enrolled in the study. The study protocol was approved by the independent ethics committee at each institution.DiscussionThis is the first study to explore the efficacy and safety of neoadjuvant chemotherapy combined with tislelizumab and LDRT in G/GEJ cancer patients, the results of which may provide novel treatment strategy for patients with locally advanced G/GEJ adenocarcinoma.Clinical trial registrationClinicalTrials.Gov, identifier NCT06266871.

Imaging of Aspiration: When to Suspect Based on Imaging of Bacterial Aspiration, Chemical Aspiration, and Foreign Body Aspiration.

Aspiration-related syndromes comprise a broad spectrum of diseases affecting the airways and lung parenchyma resulting from inadvertent entry of oropharyngeal or gastric contents into the respiratory tract. The diagnosis can be challenging given lack of self-reported symptoms and unwitnessed or silent aspiration events. Aspiration is a common finding in healthy individuals suggesting that host defenses play a critical role in the pathophysiology. In the absence of strict criterion, a high index of suspicion is necessary based on recognition of established risk factors and identification of characteristic imaging findings. Conditions predisposing to altered levels of consciousness and neuromuscular weakness can lead to dysphagia, impaired cough reflux, and subsequent aspiration. The most salient feature on imaging is the anatomic location of the abnormalities, with the superior segments of the lower lobes and posterior segments of upper lobes involved in the recumbent position, and basilar segments of lower lobes in the upright position. Acute syndromes include pneumonia, pneumonitis, and foreign body aspiration. In the more indolent form of aspiration, bronchiectasis, diffuse bronchiolitis, and interstitial lung disease can develop. A detailed understanding of associated radiographic findings for these syndromes can help to implicate aspiration as the cause for imaging abnormalities and ultimately optimize patient management.

AHP SO03 - The role of the specialist upper gastrointestinal (UGI) benign dietitian in the management of benign UGI disorders – a review of the outpatient referral base

Abstract Background Benign UGI disorders can negatively affect patients’ nutritional status by impacting on oral intake and/or through malabsorption. GSTT performs a high volume of benign UGI surgeries and is a tertiary referral centre for oesophageal reconstructions and complex hernias. The role of the dedicated specialist UGI benign dietitian was established in 2019 to provide dietetic expertise to the UGI multidisciplinary team (MDT). It supports patients before and after surgery with the aim of reducing post-operative complications, length of hospital stay, re-admissions and improving patient experience and quality of life. Method Outpatient referrals to the UGI benign dietetic service between 02/02/2024 and 06/06/2024 were reviewed for source of referral, reason for dietetic referral and UGI diagnosis. Results Twenty-five new referrals were received from a variety of clinical specialities (table 1). The primary UGI disorders of referrals are outlined in table 2, with complex hernia repair being the most common. Table 3 outlines the broad range referral reasons. Nutrition support referrals were received for the following disorders: achalasia, oesophageal stricture and following oesophageal perforation, hiatus hernia repair, cholecystectomy and oesophagectomy. All weight management referrals were for complex hernia repair patients. Referrals for the side-effects of UGI surgery included dietetic support with pancreatic exocrine insufficiency (pancreatectomy; distal gastrectomy), dumping syndrome (hiatus hernia repair) and delayed gastric emptying (oesophagectomy). Conclusion The role of the benign UGI dietitian requires skills and expertise in a broad range of dietetic interventions. The service is well utilised by surgical and non-surgical colleagues. Next steps for service development would be to review the impact of interventions on surgical and patient reported outcomes, and explore feasibility of patient groups to deliver dietetic advice (for example weight reduction prior to surgery) to improve capacity within the service.

MS O05 - HPB The ORDEAL Study: A Multi-Centre Retrospective Cohort Study Assessing the Optimal Resection for Proximal and Distal Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of cases and outcome data, no UK guidelines for surgical management, and a lack of contemporaneous UK patient data. There is debate as to whether oncological and perioperative outcomes differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD (cPD or PPPD) and limited resection (LR) in distal DA (D3/D4). This study aimed to determine the optimal type of resection for proximal and distal DA through investigating differences in long-term survival and perioperative outcomes. Method A national retrospective audit of consecutive patients from 2008-2023 undergoing curative resection for DA was conducted, with data collected anonymously via REDCap. Baseline demographics, radiological, operative, pathological and short and long-term outcomes were collated. Analysis was performed using SPSS with standard descriptive statistical methods. Chi-Square, Mann-Whitney and ANOVA were used as appropriate to compare variables and outcomes between two groups, with statistical significance set at p&amp;lt;0.05. Survival analysis (overall survival (OS) and disease-free survival (DFS)) was performed using the Kaplan–Meier method and the log-rank test to compare differences between survival curves. Time-to-event analysis was calculated with Cox regression. Results The study cohort (median age 68 years, 54.4% males) had a mean follow-up of 35.6 months. For proximal DA, 56 underwent PPPD and 87 underwent cPD; for distal DA, 26 underwent PD and 37 underwent LR. For proximal DA, survival and lymph node clearance were similar, with severe complications and no adjuvant chemotherapy independently decreasing survival. For distal DA, survival was similar despite greater lymph node clearance with PD, with age and no adjuvant chemotherapy independently decreasing survival. Complications including pancreatic fistula, delayed gastric emptying, and post-pancreatectomy haemorrhage, were comparable for proximal DA but greater with PD in distal DA. Conclusion Preliminary findings suggest adequate lymphadenectomy and comparable long-term survival for cPD and PPPD in proximal DA. For distal DA, LR is associated with similar long-term survival but lower morbidity despite greater lymph node clearance with PD. Additional records will validate these findings further.

OGC SO37 - Pyloric drainage interventions for delayed gastric conduit emptying after oesophagectomy: A single centre analysis

Abstract Background Oesophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for resectable oesophageal cancer. Delayed gastric emptying (DGE) is a common postoperative complication that results from the anatomical and physiological changes in the gastric conduit after an oesophageal resection. It is associated with an increased risk of pneumonia, anastomotic leak and prolonged hospital stay. Although several prophylactic pyloric drainage interventions have been postulated to mitigate the risk of DGE, the optimal modality remains debatable. This study aimed to define the incidence, evaluate prognostic factors, and characterise the management of DGE following oesophagectomy. Method Consecutive patients who underwent an oesophagectomy for oesophageal cancer between January 2022 and March 2024 were retrospectively identified from a hospital database. Pyloric drainage procedures consisted of expectant management, endoscopic/open pyloric Botox and pyloroplasty. Univariable and multivariable analyses were performed to define the incidence of DGE after each pyloric drainage modality, evaluate prognostic factors for DGE, and characterise the need for subsequent intervention in the management of DGE. Results The study cohort comprised 137 patients – mean age 66 years, male 78%. The incidence of DGE was 31%. Pyloroplasty had the lowest incidence of DGE (16%) followed by endoscopic botox (21%). Intra-operative pyloric drainage reduced the risk of DGE (p=0.03). The modality of prophylactic pyloric drainage used significantly influenced the risk of developing DGE (p=0.028). No significant differences were identified between patient demographics, operative approach, and oncological variables in the development of DGE. On multivariable analysis, pyloroplasty was associated with a reduced risk of DGE (OR 0.27, 95% CI 0.09 – 0.71). DGE did not influence overall survival. Conclusion DGE is a common postoperative complication which affects up to 39% of patients undergoing oesophagectomy. Patients who did not undergo a prophylactic pyloric drainage procedure during the index oesophagectomy were at an increased risk of developing DGE. Most patients with DGE (71%) require further intervention via endoscopy and botox injection. Pyloroplasty as a prophylactic drainage modality significantly reduced the risk of developing DGE compared to endoscopic botox. Further prospective randomised controlled trials are required to validate these findings.

Abstract 4134417: Cardiotoxicity Conundrum: Distinguishing Immune Checkpoint Inhibitor Myocarditis from Fluorouracil Cardiotoxicity in Concurrent Therapy

Case Description: The patient is a 37-year-old male with metastatic gastroesophageal junction adenocarcinoma presenting with chest pain and dyspnea two days after initiation of leucovorin, fluorouracil, oxaliplatin (FOLFOX), and nivolumab therapy. He was tachycardic and hypotensive with elevated cardiac biomarkers and globally reduced left ventricular systolic function. Suspecting immune checkpoint inhibitor (ICI) myocarditis versus fluorouracil (5-FU) cardiotoxicity, he was treated simultaneously for both. After starting high-dose steroids and before uridine triacetate, he had improved symptoms, cardiac function, biomarkers, and invasive hemodynamics. Though his endomyocardial biopsy did not show inflammatory cell infiltrates, his CMR demonstrated increased T1 and T2 relaxation times consistent with myocarditis. Testing revealed normal dihydropyrimidine dehydrogenase (DPD) activity. He completed uridine triacetate and was discharged on a steroid taper. At follow-up, he remained clinically stable, tolerating oxaliplatin and docetaxel (FLOT) initiation and nivolumab rechallenge without 5-FU. Discussion: This case is challenging as the presentation does not conclusively identify a causative agent. The patient’s symptom severity suggests ICI myocarditis, while the early onset points to 5-FU cardiotoxicity. His quick recovery of cardiac function after medication cessation suggests 5-FU-associated Takotsubo cardiomyopathy. His improvement after steroids raises concern for an adverse immunologic response as in ICI myocarditis or idiosyncratic reactions to oxaliplatin with 5-FU. This patient received ICI therapy and chemotherapy, increasing his risk for cardiac immune-related adverse events. His protracted 5-FU infusion increased his risk for 5-FU cardiotoxicity, but his normal DPD activity mitigates this risk. Although his biopsy was negative, it cannot exclude ICI myocarditis. By the IC-OS 2021 consensus, he meets the criteria for ICI myocarditis presenting 48 hours after nivolumab exposure with cardiogenic shock, elevated cardiac biomarkers, decline in cardiac function, and CMR with elevated T1 and T2 relaxation times. Yet, his biomarkers remained normal with nivolumab rechallenge, arguing against ICI myocarditis and suggesting 5-FU as the culprit. Early recognition and differentiation of the culprit in concurrent therapies impact management and future treatment options. Rechallenge carries risk and requires interdisciplinary collaboration to ensure patient safety.

The Advancement Stage of Gastric Cancer and the Levels of CEA and Ca19-9 in Serum and Peritoneal Lavage

Background: This study aimed to analyze the relationship between the levels of tumor markers—specifically, carcinoembryonic antigen (CEA) and Ca19-9 antigen—determined in both serum (sCEA and sCa19-9) and intraoperative peritoneal washings (pCEA and pCa19-9) and the advanced stage of gastric cancer (including the occurrence of cancer cells in cytology from abdominal fluid). Methods: This study included 47 patients with histopathologically confirmed gastric cancer or gastroesophageal junction cancer who underwent surgical treatment. The material for the cytological examination and assessment of CEA and Ca19-9 concentrations in peritoneal fluid was collected intraoperatively. Later, blood was drawn to assess the CEA and Ca19-9 concentrations in blood serum. Results: There was a statistical correlation between a positive cytology result or the presence of peritoneal carcinomatosis and a positive result for the tumor markers obtained from abdominal washings. This correlation was not observed with marker levels obtained from blood serum. The pCEA marker was highly sensitive (93.3%) and specific (93.8%) for detecting cancer cells. The pCa19-9 marker was less effective in detecting cancer but matched pCEA in identifying the absence of cancer. No differences were observed in sCEA and sCA19-9 levels between patients who underwent neoadjuvant chemotherapy and those who did not receive this treatment. However, statistical analysis showed that this relationship did not apply to pCEA and pCa19-9 levels. Conclusions: Intraoperative determinations of tumor marker levels in peritoneal washings may be a predictive factor for a poor prognosis in patients with gastric cancer.

Robotic-Assisted Endoluminal Resection of Gastroesophageal Junction Leiomyoma with Transoral Specimen Extraction: Technique, Outcome, and Safety.

Leiomyomas are benign smooth muscle tumors found at the gastroesophageal junction (GEJ) ( Mathew G, Osueni A, Carter YM. Esophageal Leiomyoma. StatPearls. StatPearls Publishing Copyright © 2024, StatPearls Publishing LLC; 2024.). Traditional management often involves total gastrectomy with esophagojejunostomy, a highly morbid procedure that impacts quality of life ( Teh JL, Shabbir A. Resection of Gastroesophageal Junction Submucosal Tumors (SMTs). In: Lomanto D, Chen WT-L, Fuentes MB (eds). Mastering Endo-Laparoscopic and Thoracoscopic Surgery: ELSA Manual. Springer Nature Singapore; 2023. pp. 207-211.). We present a case of a large endophytic GEJ leiomyoma managed with robotic-assisted endoluminal mass resection and transoral specimen extraction. A 46-year-old female with upper abdominal pain was diagnosed with a 9×3 cm lobular leiomyoma at the GEJ via computed tomography and endoscopic biopsy. The tumor was excised using the da Vinci Xi system, with transgastric endoluminal trocar placement. The GEJ defect was closed over a gastroscope, allowing visualization and continuous insufflation. Complete resection was achieved without creating a full-thickness defect. The mass was retrieved transorally with an endoscope, and the defect was repaired to minimize the risk of stenosis. The procedure lasted 236min with minimal blood loss (150mL) and with no complications. Pathology confirmed leiomyoma with negative margins. The patient was discharged on postoperative day 4 on a full liquid diet, requiring no narcotics, and was later advanced to a regular diet. No complications, readmissions, or mortality were reported at the 7-month follow-up. Robotic-assisted endoluminal GEJ mass resection is a feasible, safe technique for large benign tumors, preserving the stomach and GEJ, and thereby obviating lifestyle changes from total gastrectomy. It minimizes the risk of anastomotic leak, stricture, vagus nerve injury, gastroparesis, and reflux (Levine et al. AJR Am J Roentgenol. 157:1189-1194). Closure of the GEJ defect using an endoscope allows for adequate insufflation of the proximal stomach. When feasible, combining transoral specimen extraction enhances the benefits of this minimally invasive approach (Yin et al. Chin Clin Oncol. 13:6).