Oesophagogastric Surgery Research Articles

OGC SO05 - Prevalence of Malabsorption and Impact on Quality of Life After Oesophago-Gastric Cancer Surgery

Abstract Background Recent Cancer Research UK data highlights a concerning rise in oesophago-gastric cancers, with 9,200 new cases of oesophageal cancer cases and 7,000 new cases of gastric cancer annually, ranking them the 13th and 17th most prevalent cancers, respectively. Surgery offers potential cure, but survival rates remain modest. Procedures include oesophagectomy and gastrectomy with Roux-en-Y reconstruction. Patients frequently experience nutrition-impact symptoms (NIS) associated with malabsorption post-surgery, however limited data exits on how this malabsorption affects their quality of life (QoL). This study aimed to investigate the prevalence of malabsorption and its correlation with QoL following oesophago-gastric cancer surgery. Method A cross-sectional cohort observational study was conducted on 98 cancer-free patients aged 18 or older following oesophagectomy (57%, including 1% with colonic interposition), subtotal gastrectomy (21.4%), or total gastrectomy (20.4%) with curative intent at the Northern Oesophago-Gastric Unit in Newcastle Upon Tyne from January 2013 to December 2023. Data collection utilised a modified Gastrointestinal Symptom Rating Scale (mGSRS) and QoL questionnaire distributed via post or email. Participants assessed their QoL on a self-reported Likert-scale (0-10) for their own subjective QoL perception. SPSS statistical software was employed to explore correlations between post-surgery malabsorption and QoL outcomes within this patient cohort. Results Post-surgery, 44.3% of patients encountered weight management challenges, notably within the first year. Malabsorption was prevalent in 69.9% of patients, with common symptoms such as flatulence and reduced appetite. Steatorrhoea, experienced by 47.3% of patients, also commonly caused flatulence and urgent bowel movements. NIS prevalence varied among surgical procedures, with 64.1% post-oesophagectomy and 78% post-gastrectomy, particularly after total gastrectomy. Pancreatic enzyme replacement therapy remained underused at 9.4%. Malabsorption strongly correlated with reduced QoL scores (r=-0.583, p<0.001), regardless of the time elapsed since surgery. Patients with steatorrhoea reported significantly lower QoL scores compared to those without (MD:-1.874, 95% CI, p<0.001). Conclusion The study highlights a significant prevalence of malabsorption and impaired QoL among patients following oesophago-gastric surgery, particularly notable in those experiencing steatorrhoea. Despite medical advancements, these issues often go unrecognized. The multifaceted nature of NIS and their impact on QoL necessitate a multidisciplinary approach involving gastroenterologists, dietitians, and other healthcare professionals. This collaborative effort aims to identify underlying factors contributing to malabsorption, provide consistent dietetics support, and manage symptoms effectively throughout the patient's recovery. Standardised guidelines are essential for ensuring comprehensive care and addressing both physical and psychosocial aspects, thereby enhancing overall postoperative QoL and long-term health outcomes.

OGC SO12 - Extended Venous Thromboembolism Prophylaxis in Postoperative Oesophagogastric Cancer Patients: A Completed Audit

Abstract Background Venous thromboembolism (VTE) is a life-threatening complication for cancer patients undergoing oesophagogastric surgery. The NICE recommends extending pharmacological VTE prophylaxis to 28 days for patients undergoing major abdominal cancer surgery. While the effectiveness of in-hospital VTE prophylaxis is well-documented, the optimal duration for postoperative VTE prophylaxis remains a subject of debate. This study aims to evaluate the prescribing compliance, effectiveness, and safety of extending VTE prophylaxis to 28 days following hospital discharge (HD), a policy adopted trust-wide since 2014. Method This is an 11-year retrospective study from July 2012-2022, followed by a complete audit cycle conducted between January 2023-2024. The study included all patients who underwent cardio-esophagectomy or gastrectomy for oesophagogastric cancers. Exclusion criteria comprised patients who died during the index admission, those who underwent benign oesophagogastric surgery or local excision of gastrointestinal stromal tumours (GIST), and patients with peripherally inserted central catheter (PICC) line-associated VTE. The primary outcome measured was the prescribing compliance of 28-day VTE prophylaxis post-hospital discharge. Secondary endpoints included the incidence of VTE and bleeding complications necessitating hospital readmission within 28 days of discharge. Results Our study included 582 patients, showing that post-2014, 423 out of 490 patients (86.3%) were discharged with 28-day VTE prophylaxis, compared to 13 out of 92 patients (14.1%) pre-2014, indicating a significant improvement (p<0.05). Only one patient (0.17%) developed VTE more than 28 days post-discharge, and no readmissions due to bleeding complications. In the subsequent audit, 63 out of 68 patients (92.6%) received the prophylaxis, further increasing prescribing compliance. Comparing the two periods, compliance improved from 86.3% to 92.6%, though not statistically significant (p=0.145). Overall, VTE incidence was minimised from 0.17% to 0%, with no readmissions due to bleeding complications. Conclusion Routine extended VTE prophylaxis for 28 days post-hospital discharge should be recommended for cancer patients undergoing oesophagogastric surgery. This practice has significantly improved prescribing compliance rates, reduced post-hospital discharge VTE incidence, and demonstrated safety, with no hospital readmissions due to bleeding complications.

AHP SO07 - Dietetic Outpatient Service to Patients undergoing Oesophagogastric (OG) Surgery for Cancer

Abstract Background Nutrition is a modifiable risk factor impacting surgical outcomes in OG cancer. Its key role influencing health related quality of life is emerging with improved survivorship. Guidelines depicting optimal timing and type of dietetic intervention for this patient group are unclear. In order to best direct dietetic care, optimise timing of nutritional interventions and understand demand for service it is important to reflect on current provision. This audit aimed to describe the dietetic outpatient service to patients undergoing OG Surgery for cancer in a national centre for treatment of oesophageal cancer. Method A retrospective review of dietetic records and statistics. Patients who underwent oesophagectomy (O), gastrectomy (G) or subtotal gastrectomy (STG) for cancer between May 2022- May 2023 were included. Results 63 patients were included: 38 O, 17 TG, 8 STG. 11 were seen by the dietitian at first visit to OG Clinic (9 O, 1 TG, 1 STG) – 6 had an elective feeding tube (FT) inserted for neoadjuvant treatment (5 O, 1 STG). 83% attended a surgical pre-assessment dietetic appointment (36 O, 14 TG, 2 STG). 86% were reviewed within 1 month post O or TG, 75% post STG. 258 dietetic interventions occurred in the first year post-op (median 3.5, range 0-14). 64% in the first 3 months(m) post op, 16% at 3-6m, 10% at 6-9m, 10% at 9-12m. Conclusion In this high nutritional risk group only 18% are assessed by a dietitian at first visit to UGI MDT clinic. There is a successful pathway for immediate peri-operative dietetic care in patients post O and TG. The pathway for STG is less well established. Dietetic interventions are concentrated in the first 3 months after surgery. There is no established protocol to support longer term nutritional needs into survivorship. To inform practice a measure of patient experience and needs would be useful, to explore best delivery format and access routes to future services.

BN SO33 - The complex benign multi-disciplinary team meeting - a paradigm shift in decision making for benign oesophagogastric surgery

Abstract Background Decision making in benign OG pathology can be particularly challenging given the overlap with functional disorders, such as reflux hypersensitivity. A specialist benign oesophagogastric (OG) multidisciplinary team (MDT) may improve our ability to triage potential surgical candidates from those with functional conditions. Unlike in OG cancer, there is a paucity of evidence to support an MDT based approach in benign OG surgery. This study aims to report our experience of introducing a specialist benign OG MDT in an OG tertiary centre in the UK, examining the effect on decision making and an assessment of its acceptability and utility to clinicians. Method A review of consecutive cases discussed in the specialist benign OG MDT since inception in 2022 was undertaken. We reviewed indications, treatment plans and outcomes, any alteration in treatment pathway and final decisions. The primary outcome was the proportion of patients with a change in management as a result of MDT discussion. Where applicable, results were reported using descriptive statistics. A seven-item electronic questionnaire was also circulated to MDT members (OG surgeons, specialist gastroenterologists, GI radiographers, GI physiologists, and doctors in training), to assess the acceptability and perceived utility of the meetings. Results 74 patient cases were discussed (median age 57.5 (25-79) years). 71/74 (96.0%) of referrals were made by OG surgeons, most commonly to discuss anti-reflux procedures (53/74 (71.6%)). 34/74 (45.9%) patients had undergone previous surgery, most commonly laparoscopic fundoplication. MDT discussion led to a change in management in 43/74 (58.1%) case with recommendations of further investigation (23.0%), further OG clinic review (18.9%) and 21.6% listed for surgery. 12/74 (16.2%) were referred to other specialist services, including clinical psychology. Survey confirmed that all MDT members found their understanding of oesophageal physiology and subsequent decision-making ability in clinic was greatly enhanced. Conclusion Our results show that the complex benign MDT is an effective tool, demonstrating changes to management in over half of cases discussed, including recommending surgery less frequently following specialist review of physiology investigations. Such tests effectively identify functional disorders, such as rumination, highlighting a need for clear onward referral pathways involving specialist psychologists. The meetings have also proven to be valuable learning tools for all attendees of all grades. We strongly believe that adopting an MDT approach to benign OG conditions will enhance collaborative decision making, improve patient outcomes and therefore should be nationally mandated and recommended through AUGIS guidelines.

EGS SO06 - Emergency provision for Oesophago-Gastric Surgery in the United Kingdom: A National Survey

Abstract Background Oesophagogastric (OG) emergency conditions may require specialised intervention in centralised OG cancer surgery units. Recently published AUGIS OG commissioning guidance recommends OG units provide 24/7 on-call cover for internal and external OG emergency referrals with a formalised rota. However, there may be widespread inconsistent provision of OG emergency services across United Kingdom (UK) regions with significant workforce, capacity, and funding challenges. This may lead to barriers to provision of on-call OG services. Currently there is no research that establishes current OG on-call coverage or explores OG surgeons’ perceptions and attitudes towards providing this service. Method An 11-item electronic questionnaire was developed at an OG cancer unit to identify OG consultant emergency on-call coverage at NHS OG cancer units in the UK. The questionnaire was initially piloted among OG surgeons for refinement and subsequently disseminated through professional networks (AUGIS), direct contact, and snowballing. It was active for three weeks in January 2024. Secondary outcomes included: identifying barriers to providing an emergency OG service; defining the scope of conditions acceptable for transfer; understanding current referral mechanisms and examining OG consultant attitudes and perceptions towards providing an on-call OG service. Results 71 consultant OG surgeons from 26 UK OG cancer units responded (Figure 1). 61% (n=43) report participating in a 24/7 formalised emergency OG on-call rota, staffed by a median of 5 (range 3-8) surgeons. Among the nine respondents from three centres without a formal OG emergency service, all cited limited funding as the primary barrier. Only 31% (n=19) used auditable referral mechanisms like email or online systems. 97% percent (n=69) of respondents perceive an OG emergency service to be beneficial for patients, and 86% (n=61) agreed it should be nationally mandated for OG cancer units to provide a 24/7 service. Conclusion Consultant OG surgeons recognize the importance of delivering high-quality OG emergency services. However, the data indicates inconsistent delivery across the UK. Given the seriousness of OG emergencies, mandatory provision of this service with appropriate funding and remuneration is essential. Several workforce challenges, including potential impacts on OG cancer resection volume and provision of General Surgical on-call, need to be addressed. Ultimately, patients require timely and specialised intervention. As one respondent emphasized: "A situation where surgeons in non-OG centres can spend a whole night ringing around various OG centres looking for help with a Boerhaave perforation is unacceptable."

OGC O02 - Measurement of functional, psychosocial, and quality of life impacts of Robotic versus Hybrid Oesophago-gastrectomy

Abstract Background Since the introduction of Robotic-Assisted Minimally-Invasive Oesophago-gastrectomy (RAMIO), comparisons to other surgical approaches have focussed primarily on peri-operative and oncological outcomes. Few studies have focused on quality-of-life measures once the patient has been discharged home. We sought to compare physical, psychosocial, sleep, pain and employment related measures at six weeks following discharge in patients undergoing RAMIO versus Hybrid Oesophago-gastrectomy. Method We performed a prospective cohort study comparing RAMIO and Hybrid Oesophago-gastrectomy. Twenty-five consecutive patients on a curative surgical pathway were recruited to each group. Participants were contacted via telephone pre-operatively and six weeks post-operatively. Parameters studied were: physical activity, social activity, sleep, pain control, and employment. Psychological wellbeing was measured using the Hospital Anxiety and Depression Scale, and quality of life with the European Organisation for Research and Treatment of Cancer questionnaires C30 (all cancer patients) and OG25 (patients undergoing oesophago-gastric cancer treatment). Results were analysed using Chi Square and Mann-Whitney-U statistical tests. Results There were no differences in age, ASA, or anaerobic threshold between study groups. At six weeks the RAMIO group was more likely than Hybrid to have returned to pre-operative physical and social activity (physical 7/25 vs. 1/25, p=0.04, social 13/25 vs. 5/25, p=0.03). The RAMIO group stopped regular analgesia earlier, and required fewer opiates. Patients were more likely to return to work in the RAMIO group (7/15 vs. 1/12,p=0.04). The RAMIO group had fewer cases of depression (2 vs. 9, p=0.03), lower QLQ C30 and OG25 scores, and reported higher overall health and quality of life scores (p=0.001). Conclusion We have demonstrated an improvement in physical and social activity, a faster return to work, a reduction in analgesia requirements, lower rates of depression and improved health and quality of life, six weeks post-operatively when comparing RAMIO to hybrid oesophago-gastrectomy. This study has highlighted additional considerations for the selection of surgical modality in oesophago-gastrectomy beyond peri-operative outcomes. Further investigation across a larger sample size and longer time frame to quantify the full spectrum of potential benefits of robotic oesophago-gastric surgery is warranted.

Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS)/perioperative quality initiative (POQI) consensus statement on prehabilitation in oesophagogastric surgery.

Prehabilitation is safe, feasible and may improve a range of outcomes in patients with oesophago-gastric cancer (OGC). Recent studies have suggested the potential of prehabilitation to improve body composition, sarcopenia and physical fitness, reduce surgical complications and improve quality of life. Despite this, prehabilitation services are not offered throughout all OGC centres in the UK. Where prehabilitation is offered, delivery and definitions vary significantly, as do funding sources and access. A professional association endorsed series of consensus meetings were conducted using a modified Delphi process developed by the Peri-Operative Quality Initiative (POQI) to identify and refine consensus statements relating to the development and delivery of prehabilitation services for OGC patients. Participants from a variety of disciplines were identified based on a track record of published studies in the field of prehabilitation and/or practice experience encompassing prehabilitation of OGC patients. Approval from the POQI board was obtained and independent supervision provided by POQI. A total of 20 statements were developed and agreed by 26 participants over a preliminary meeting and 2 semi-structured formal POQI meetings. Ten research themes were identified. In the case of one statement, consensus was not reached and the statement was recorded and developed into a research theme. A strong recommendation was made for the majority of the consensus statements (17 of 20). Consensus statements encompassing the interventions and outcomes of prehabilitation services in oesophago-gastric cancer surgery have been developed to inform the implementation of programmes.

ThP3.3 - Prophylactic Endoluminal Vacuum Therapy – towards an era of reducing leak related morbidity after elective oesophago-gastric resection

Abstract Aims Uncontrolled sepsis following leak from oesophago-gastric surgery is a devastating condition with increased morbidity & mortality affecting longer-term cancer-free survival in patients with cancer resections. We hypothesised that endoluminal vacuum therapy (EVT), previously used to treat leaks, could be used in prophylactic settings to provide source-control, prevent mediastinitis and minimise sepsis related morbidity from leaks. Methods An ad-hocEVT device was created using VACgranufoam (KCI)and a nasogastric-tube(16/18Fr), and placed intraluminally across the repair/anastomosis in select high-risk cases. Continuous negative pressure(75–125mmHg) was applied. Assessment of the repair-site/anastomosis was performed by radiology, endoscopy, clinical assessment or a combination following cessation of EVT. Results 27 patients had prophylactic EVT; M:F ratio was 3:1 and the median age was 68 years (range: 41-82years). 26surgeries were for cancer, while 1 was benign. The rationale for prophylactic EVT included patient related (10), technical factors (16) or both (1). The median duration of prophylactic EVT was 7 days (range: 4-14days). The median length-of-stay was 19.7 days (range: 6-96 days), the two longest admissions were unrelated to the anastomosis(prolonged chyle-leak, and long-term-sequelae of life-threatening bleed). One-patient developed a full-thickness microleak at endoscopic-evaluation, yet remained well with no systemic signs of sepsis, successfully managed with luminalEVT for a further 6days in a ward-based environment. Though prophylacticEVT did not prevent the leak, it significantly minimised the systemic hit that traditionally results from leak and associated mediastinal sepsis. Conclusions ProphylacticEVT is a useful adjunct for management of patients with a high risk for leak, though not a substitute for good surgical technique. There are no short-term complications, yet the additional morbidity, mortality and length-of-stay associated with a fully-fledged leak is avoided. Randomised-controlled-trials are required to further standardise selection criteria, assess potential patient benefit and longer-term impact on survivorship.

437. MEASUREMENT OF FUNCTIONAL, PSYCHOSOCIAL, AND QUALITY OF LIFE IMPACTS OF ROBOTIC VERSUS HYBRID OESOPHAGO-GASTRECTOMY

Abstract Background Since the introduction of Robotic-Assisted Minimally-Invasive Oesophago-gastrectomy (RAMIO), comparisons to other surgical approaches have focussed primarily on peri-operative and oncological outcomes. Few studies have focused on quality-of-life measures once the patient has been discharged home. We sought to compare physical, psychosocial, sleep, pain and employment related measures at six weeks following discharge in patients undergoing RAMIO versus Hybrid Oesophago-gastrectomy. Methods We performed a prospective cohort study comparing RAMIO and Hybrid Oesophago-gastrectomy. Twenty-five consecutive patients on a curative surgical pathway were recruited to each group. Participants were contacted via telephone pre-operatively and six weeks post-operatively. Parameters studied were: physical activity, social activity, sleep, pain control, and employment. Psychological wellbeing was measured using the Hospital Anxiety and Depression Scale, and quality of life with the European Organisation for Research and Treatment of Cancer questionnaires C30 (all cancer patients) and OG25 (patients undergoing oesophago-gastric cancer treatment). Results were analysed using Chi Square and Mann-Whitney-U statistical tests. Results There were no differences in age, ASA, or anaerobic threshold between study groups. At six weeks the RAMIO group was more likely than Hybrid to have returned to pre-operative physical and social activity (physical 7/25 vs. 1/25, p=0.04, social 13/25 vs. 5/25, p=0.03). The RAMIO group stopped regular analgesia earlier, and required fewer opiates. Patients were more likely to return to work in the RAMIO group (7/15 vs. 1/12,p=0.04). The RAMIO group had fewer cases of depression (2 vs. 9, p=0.03), lower QLQ C30 and OG25 scores, and reported higher overall health and quality of life scores (p=0.001). Conclusion We have demonstrated an improvement in physical and social activity, a faster return to work, a reduction in analgesia requirements, lower rates of depression and improved health and quality of life, six weeks post-operatively when comparing RAMIO to Hybrid Oesophago-Gastrectomy. This study has highlighted additional considerations for the selection of surgical modality in oesophago-gastrectomy beyond peri-operative outcomes. Further investigation across a larger sample size and longer time frame to quantify the full spectrum of potential benefits of robotic oesophago-gastric surgery is warranted.

Opinion, uptake and current practice of robot-assisted upper gastrointestinal and oesophagogastric surgery in the UK: AUGIS national survey results.

The uptake of upper gastrointestinal (GI) robotic surgery in the United Kingdom (UK), and Europe more widely, is expanding rapidly. This study aims to present a current snapshot of the practice and opinions of the upper GI community with reference to robotic surgery, with an emphasis on tertiary cancer (oesophagogastric) resection centres. An electronic survey was circulated to the UK upper GI surgical community via national mailing lists, social media and at an open-invitation conference on robotic upper GI surgery in January 2023. The survey included questions on surgeons' current practice or planned adoption (if any) of robotics at individual and unit level, and their opinions on robotic upper GI surgery in general. Priority ranking and Likert-scale response options were used. In total, 81 respondents from 43 hospitals were included. Thirty-four resectional centres responded, including 30 of 31 (97%) recognised upper GI cancer centres in England. Respondents reported performing robotic surgery in 21 of 34 (61.8%) resectional centres, with a median of 65 procedures per centre performed at the time of the survey (range 0-500, interquartile range 93.75). Every centre without a robotic programme expressed a desire or had active plans to implement one. Respondents ranked surgeon ergonomics as the most important reason for pursuing robotics, followed by improvements in patient outcomes and oncological efficacy. Robotic upper GI practice is nascent but rapidly growing in the UK with plans for uptake in almost all tertiary centres. There is growing opinion that this is likely to become the predominant surgical approach in future with benefits to both patients and surgeons. This snapshot offers a point of reference to all stakeholders in upper GI surgery.

OGC P62 Preoperative IVC filter insertion for oesophagogastric cancer surgery patients

Abstract Background Venous thromboembolism (VTE) is a life-threatening complication in cancer patients undergoing oesophagogastric surgery. Oesophagogastric cancer patients are at high risk of developing perioperative VTE due to neoadjuvant chemotherapy, prolonged immobilisation, reduced oral intake, and increased risk of dehydration. NICE guideline [NG158] recommends considering an inferior vena cava (IVC) filter for patients with proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) when anticoagulation treatment is contraindicated. This study evaluates the effectiveness and safety of preventing perioperative VTE recurrence via the preoperative insertion of the IVC filter after adopting this as a trust-wide policy in 2012. Methods This is a 10-year retrospective study from July 2012-2022. All patients who underwent cardio-oesophagectomy or gastrectomy for oesophagogastric cancers were included. All patients who underwent benign oesophagogastric surgery or local excision of GIST were excluded. The primary outcome includes the incidence of perioperative VTE recurrence following preoperative insertion of an IVC filter. The secondary outcome includes the inpatient and 30-day complications and mortality following the insertion of the IVC filter. Results 582 patients were included in our study. 37/582 (6.4%) patients developed preoperative VTE, in which 25/37 (67.6%) patients were diagnosed with PE, whereas 12/37 (32.4%) patients had proximal DVT. 30/37 (81.1%) patients underwent preoperative IVC filter insertion, while 7/37 (18.9%) did not. Of these 7 patients, 1 patient developed popliteal DVT 9 months after surgery. There was a statistically significant difference in preventing perioperative VTE recurrence through IVC filter insertion before surgery (p<0.05). IVC filters were safely removed in all patients postoperatively. No inpatient or postprocedural 30-day complications or mortality was identified. Conclusions This study has demonstrated that preoperative IVC filter insertion could prevent perioperative VTE recurrence in cancer patients who underwent oesophagogastric surgery. However, the retrospective nature of this study and the relatively small sample size are the main limitations. Preoperative IVC filter insertion is deemed safe, given no postprocedural morbidity or complications were identified.

584 Extended VTE Prophylaxis in Patients Undergoing Oesophagogastric Cancer Surgery

Abstract Aim Venous thromboembolism (VTE) is a life-threatening complication in cancer patients undergoing surgery. NICE recommends VTE-prophylaxis to 28days for patients undergoing major abdominal cancer surgery. The efficacy of in-hospital VTE-prophylaxis is well-documented, but the optimal duration of postoperative VTE-prophylaxis remains controversial. Patients undergoing oesophagogastric cancer surgery have a higher risk of VTE due to suboptimal oral intake, dehydration, need for adjuvant and neoadjuvant chemotherapy. Hence in 2014, extended VTE-prophylaxis to 28days from hospital discharge (HD) was adopted as a departmental policy. This study aims to evaluate its effectiveness, prescribing compliance and safety. Method This is a 10-year retrospective study from July 2012-2022. All patients who underwent cardio-oesophagectomy or gastrectomy for oesophagogastric cancers were included. Patients who died during the index admission, benign oesophagogastric surgery including excision of GIST, and central line associated VTE were excluded. The primary outcome is prescribing compliance with 28-day VTE prophylaxis from HD. The secondary outcome includes the incidence of VTE and bleeding complications requiring hospital readmission within 28days from HD. Results 582 patients were included in our study. Since 2014, 423/490patients (86.3%) have been discharged with 28days VTE-prophylaxis from HD compared to pre-2014 (13/92patients,14.1%). There was a statistically significant difference in improving prescribing compliance following the introduction of this policy (p<0.05). No patient was readmitted due to bleeding complications. Only 1 patient (1/582,0.17%) developed VTE within 28days from HD. Conclusions We recommend extending VTE-prophylaxis for 28days from hospital discharge for all patients undergoing oesophagogastric cancer surgery. This improves prescribing compliance, reduces the incidence of post-discharge VTE and is safe.

OGC P37 Towards an era of eliminating leak related morbidity from major oesophago-gastric surgery

Abstract Background A leak following oesophago-gastric surgery remains a life-threatening complication associated with a long intensive care stay and high mortality and morbidity. We hypothesised that Endoluminal Vacuum Therapy (EVT) could be used prophylactically to provide source control, prevent mediastinitis and minimise sepsis related morbidity if breakdown of an oesophageal or gastric anastomosis or repair occurred. In the first instance, this could be a particularly attractive adjunct in cases where technical and/or patient factors deem an anastomosis or repair as high risk. Methods We collected data prospectively from all patients where a prophylactic EVT device was placed during elective oesophago-gastric surgery. Primary outcome measures included length of stay (LOS) and post-operative leak rate. Prophylactic EVT was provided using an ad-hoc EVT device constructed by suturing a piece of V.A.C granufoam (KCI) to the end of an 18Fr NG tube and positioning this intraluminally across the anastomosis or area of repair at the time of surgery using endoscopic guidance. Continuous negative pressure of between 75 and 125mmHg was applied. Following removal of the EVT device, assessment of the integrity of the anastomosis or repair was made using one, or a combination of endoscopic assessment, CT with oral contrast, and clinical assessment. Results Prophylactic EVT was utilised in 9 patients; M:F ratio=7:2, median age 72 years (range 50–80). 8 patients had ASA 3, and 1 had ASA 2. The index surgery was resection of an epithelial cancer in 7 patients (3 partial/total gastrectomies, 4 oesophagectomies), resection of a gastric GIST in 1 patient, and a Hellers myotomy in 1 patient. All anastomosis/repairs were deemed high risk due to technical(n=3), patient(n=4) or combined (n=2) factors. Prophylactic EVT was placed for a median of 6 days (range 4–10). The integrity of the anastomosis/repair was assessed using both CT and gastroscopy (n=3), CT alone (n=3), gastroscopy alone (n=2), and clinical grounds (n=1). One patient was found to have a full thickness oesophageal defect at their first endoscopic assessment. This was managed with a further period of intraluminal EVT until the oesophageal defect healed. The patient remained clinically well throughout and was managed entirely with ward-based care. The median LOS was 11 days (range 7–96). The two longest stays were secondary to a prolonged chyle leak and longer term sequelae of a life threatening on-table bleed. In all cases the site of repair remained healthy with no evidence of early stricturing. Conclusions Prophylactic EVT therapy was safe and did not result in any short-term adverse events in this small cohort of patients. Although it may not prevent breakdown at the site of oesophageal anastomosis/repair and is not an alternative to sound surgical technique, the use of prophylactic EVT in high risk anastomosis could be beneficial in preventing life threatening sepsis and associated systemic effects resulting from inadequate source control. Current studies are under way to look at longer term outcomes in the form of prospective cohort studies and randomised controlled trials. This provides the oesophago-gastric community the unique opportunity to collectively eliminate life threatening leak related morbidity and mortality for once and for all.

A O04 Identifying Predictive Factors for Prolonged use of Nutritional Support After Oesophagogastric Cancer Resections

Abstract Background In the era of evidence-based practice, there remains significant variation in peri-operative nutritional strategies for patients undergoing oesophagogastric (OG) cancer resections. Although dietary support is accepted as essential for this patient group, the use of feeding adjuncts, such as parenteral nutrition (PN) or enteral feeding tubes, varies widely. In addition, the clinical benefit of peri-operative supplementary feeding remains uncertain, especially since the evolution to minimally invasive OG surgery, introduction of ERAS and drive for early oral intake. Despite improvements in peri-operative nutrition pathways, risks associated with feeding adjuncts remain. There are also increased financial costs associated with peri-operative nutritional support which require consideration. After analysing unit peri-operative outcomes, it was hypothesised that routine feeding adjunct use may be unnecessary for most patients who meet oral nutritional goals early and should instead be reserved for patients with an increased risk of supplementary post-operative nutritional requirement.The primary aim of this study was to evaluate which clinicopathological factors were associated with prolonged use of PN after OG surgery. The secondary aim was to evaluate the associated morbidity and healthcare costs of PN use. Methods A retrospective cohort study of 518 patients undergoing oesophagectomy or total gastrectomy for cancer at Guy's and St Thomas’ NHS Foundation Trust, London, UK, between 2015 and 2021. The standard feeding regimen after oeosphagectomy or total gastrectomy at St Thomas’ involves PN for a median of eight days post-operatively. Oral intake is initiated after a contrast swallow is performed on day three for uncomplicated patients. The primary outcome was prolonged use of post-operative PN, defined as nine-days or more PN during the index admission. Clinicopathological characteristics were compared using the Chi square test. The relationship between these characteristics and PN use was evaluated using logistic regression analysis, providing odds ratios (OR) with 95% confidence intervals (CI) adjusting for age, sex, BMI, comorbidities, histology, anastomosis location, surgical access, pre-operative weight loss, pre-operative supplementary feeding. The prognostic ability of clinicopathological characteristics to predict prolonged PN use were compared using receiver operator characteristic (ROC) analysis to calculate area under the curve (AUC). An economic model was developed using described PN related complication rates from the published literature and 2021 NHS tariffs. Results Predictive factors for prolonged PN use on adjusted analysis included age over 65 (HR 1.70 95% CI 1.14–2.52), pre-operative weight loss (0–10%: HR 1.67 95% CI 1.09–2.56, >10%: HR 2.21 95% CI 1.05–4.66), open surgery (HR 1.64 95% CI 1.03–2.62) and an OG anastomosis located in the neck (HR 2.50 95% CI 1.35–4.65). Patients with a BMI over 25 had a lower chance of prolonged PN use (HR 0.65 95% CI 0.43–0.98). Other characteristics were not prognostic. ROC curve analysis demonstrated that anastomosis location (AUC 0.59), age (AUC 0.57) and surgical access (AUC 0.56) were the most prognostic factors. The combination of parameters included in the adjusted model provided an AUC of 0.67. Potential PN and line related complications included: deranged liver biochemistry (18.0%), deranged blood sugars (9%), line infection (1.4%) and line thrombus (0.8%). An eight-day course of PN was calculated to cost £884 with average treatment related complication costs of £176 per patient. Using the mean number of patients treated per year over the past three years (N = 112) the projected service savings were £75,912 per year if PN was reserved for patients with high-risk characteristics. Conclusions This study has demonstrated that several patient and treatment related factors are associated with an increased risk of needing prolonged adjunctive nutritional support after OG surgery. As surgical practice has evolved to minimally invasive surgery and ERAS with subsequently low peri-operative complication rates, the clinical benefits of short course adjuvant feeding may not be seen in patients who progress promptly to appropriate oral intake. Therefore, we propose the introduction of a tailored treatment pathway, based on pre-operative characteristics which excludes the routine use of post-operative feeding for low-risk patients. The study also demonstrates that a change in practice can lead to considerable cost savings. The model demonstrated in this study can be applied to all feeding adjuncts and can therefore be universally adopted in any UK/global unit regardless of supplementary feeding route preference. It will encourage high-performance by promoting a patient-centred and individualised approach to peri-operative nutrition which is currently lacking in many aspects of our clinical practice. Further work in the form of a randomised trial may be explored to better understand the need and benefit of supplementary feeding methods after OG resection as the specialty continues to evolve.

OGC P16 What is the prevalence of weight loss in patients undergoing oesophago-gastric surgery and the effect of dietetic intervention pre-op

Abstract Background Patients with oesophago-gastric (OG) cancer are one of the highest risk groups for malnutrition. Nutrition plays a vital role in supporting this patient group. NICE guidelines (2018) recommend adults with OG cancer have tailored specialist dietetic support before, during and after radical treatment. Unfortunately the research available suggests there are low rates of preoperative dietetic input in this population, which are associated with poorer outcomes. Methods Data was obtained via informatics looking at patients who had an oesophagectomy or total gastrectomy between the years of March 2018 –2020 and were followed up at the Queen Elizabeth Hospital Birmingham. A sample of 66 patients was taken. Data was collected on the surgery type, weight changes and whether there was any dietetic input before and / or after surgery. Results 79% (52) patients had an oesophagectomy and 21% (14) had a total gastrectomy. Weight loss across all patients post-surgery was apparent post op at 3, 6 and 12 months. Clinically significant weight loss (>10%) was demonstrated at 3 months (27%), 6 months (17%) and 12 months (26%). Unfortunately data was not available for 20% (6 months) and 36% at (12 months). Only 16 (24%) patients were known to a dietitian pre-op. Out of these 8 (50%) had a feeding tube inserted pre-operatively, 7 of the patients used the tube for enteral feeding. 5 (31%) were seen for oral nutrition support and 3 (19%) for food first approach. 100% of patient had a feeding tube inserted following surgery. 100% of patients had been seen by a dietitian post op both as an inpatient and outpatient. The percentage of patients seen by a dietitian prior to surgery that had clinically significant weight loss post-op was less than those that were not seen by a dietitian pre op (ie 19% vs 24% at 6 months respectively). Conclusions Patients that undergo OG surgery experience clinically significant weight loss postoperatively. The data collected highlights that dietetic input pre-op can lead to less weight loss following surgery. Additional dietetic funding and the set up of a pre-treatment clinic would enable more patients to be seen prior to surgery. Further research needs to be done with a larger sample size over a longer time-frame to provide more representative results on the effects of dietetic input both pre and post surgery.

OGBN O05 Safety and efficacy of endoscopic self-expanding stent insertion for benign oesophageal strictures – retrospective review of a single-centre case series

Abstract Background Benign oesophageal strictures (BOS) are common and are most often managed with endoscopic balloon or bougie dilation. While self-expanding stents (SES) are a key tool for managing malignant strictures, their role in management of BOS is less well defined, usually being reserved for refractory strictures. Potential benefits include reduced frequency of intervention to stabilise nutritional status, and risks include migration, perforation or erosion. We conducted a single-centre retrospective review of our experience using SES for BOS to evaluate their safety and efficacy. Methods All patients undergoing SES insertion at a tertiary oesophago-gastric surgery unit between November 2015 and November 2020 were retrospectively identified using cross-referencing across 3 internal software systems. Patients undergoing primary SES insertion for BOS were identified, records were retrieved and reviewed. Data was collected on pre-insertion stricture management, post-procedure complications and outcomes including further interventions within the next year. Results During the study period, 425 oesophageal SES were inserted. From these cases, 18 patients underwent primary SES insertion for BOS. 14/18 (78%) of patients were male with a mean age of 68 years. Causes of BOS were reflux (7, 39%), 360 degree radiofrequency ablation of dysplastic Barrett's oesophagus (7, 39%), radiotherapy for squamous cell carcinoma (2, 11%), post-achalasia treatment stricture (1, 6%) and anastomotic stricture (1, 6%). In the 12 months prior to SES insertion, patients underwent a median of 3 (IQR 2–4) balloon dilations. During the immediate preceding month, patients underwent a median of 1 (IQR 0–1) dilations. There were no cases of perforation, bleeding or erosion associated with SES insertion. 5 of 18 (28%) stents migrated. Median interval to the next endoscopy was just over 5 weeks (36 days (IQR 27.25–48). During the following 12 months after stent insertion, patients underwent a median of 5 (IQR 3–9.5) further endoscopies after primary stent insertion. Conclusions Stent insertion for BOS is safe and can provide a period of several weeks before further intervention is required. This may facilitate a period during which oral nutrition can be improved. However, SES for BOS is associated with a significant rate of migration, and patients continue to require frequent interventions after stent insertion. We suggest that SES insertion in this setting should be reserved for selected cases where intensive early dilation has failed to achieve progression in diameter with improvement in symptoms and nutrition as part of a standardised approach to improve management of BOS.

412. FEASIBILITY AND SAFETY OF MINIMALLY INVASIVE SURGERY FOR OESOPHAGEAL DUPLICATION CYST IN ADULTS– EXPERIENCE FROM AN OESOPHAGO-GASTRIC SURGERY UNIT

Abstract Oesophageal duplication cyst (ODC) is a rare congenital anomaly of the foregut. The reports of ODCs presenting in adulthood is relatively rare. Surgical excision is the ideal treatment. Traditionally, the excision is performed via a thoracotomy with its resultant morbidity. Minimally invasive surgical (MIS) approaches are feasible and can potentially reduce the postoperative discomfort and reduce the hospital stay. We aimed to study the feasibility and safety of MIS for ODC in adults. A retrospective review of all adult patients with ODCs treated in an oesophago-gastric surgery unit, between January 2015 and March 2022, was performed. All patients received MIS. The demographic, clinico-radiological, and operative details and outcomes were analysed. Nine patients (Female 7; mean age, 36.2 ± 4.4 years) were included. Chest pain was the commonest symptom (44.0%). Oesophago-gastroscopy showed normal mucosa in all patients. Endoscopic-ultrasound was performed in all except one; no cysts had atypical features. The cysts were frequently located in the distal thoracic oesophagus (78%) and the median (range) cyst size was 6.3(3.9–13.5) cm. All patients received MIS (Thoracoscopy,8; Thoraco-laparoscopic, 1); no conversion to open surgery. The techniques resection techniques were enucleation (5), stapler-assisted resection (3) or partial excision (1). The 30-day morbidity was 22.2% (Staple line leakthoracoscopic repair, 1; pleural collectionimage-guided drainage, 1). The median (range) hospital stay was 7(3–25) days and there was no mortality. MIS is feasible and safe for the management of adult ODCs and should be offered to patients, irrespective of the timing of its presentation or the location and size of the cyst.

COMPARATIVE STUDY OF SINGLE LAYER INESTINAL ANASTOMOSIS AND DOUBLE LAYER INTESINAL ANASTOMOSIS

Background: Gastrointestinal anastomosis is one of the most common procedures being performed in oesophagogastric, hepatobiliary, bariatric, small bowel and colorectal surgery. There are still conflicting views regarding suitability of single layer and double layer anastomotic technique. Methods: This comparative study was conducted at Patna Medical College and Hospital,Patna in which 48 patients were repaired with single layer anastomosis and 48 were repaired with double layer intestinal anastomosis. Single layer intestinal anastomosis was carried using extramucosal technique with 2-0 vicryl suture (round body). Double layer anastomosis was carried out using interrupted 2-0 vicryl suture for both inner (continuous) and outer ( Interrupted) layer.End to end colocolic,end to side ileocolic,end to end ileoileal,side to side ileoileal,end to end jejunoileal and end to end jejunojejunal anastomosis were performed. Each group was compared for anastomotic leak, time required to construct the anastomosis and length of hospital stay. Results: The mean time taken for anastomosis (15±2 minutes in single layer anastomosis versus 32±5 minutes in double layer) and the length of hospital stay was same in both the groups.There was 1 anastomosis leak in single layer anastomosis group and 3 in double layer group. Conclusion: It can be concluded that single layered extramucosal continuous intestinal anastomosis is equally safe and perhaps more cost effective than the conventional double layered method and may represent the optimal choice for routine surgical practice.

The current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review

Background3D reconstruction technology could revolutionise medicine. Within surgery, 3D reconstruction has a growing role in operative planning and procedures, surgical education and training as well as patient engagement. Whilst virtual and 3D printed models are already used in many surgical specialities, oesophagogastric surgery has been slow in their adoption. Therefore, the authors undertook a scoping review to clarify the current and future roles of 3D modelling in oesophagogastric surgery, highlighting gaps in the literature and implications for future research.MethodsA scoping review protocol was developed using a comprehensive search strategy based on internationally accepted guidelines and tailored for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). This is available through the Open Science Framework (osf.io/ta789) and was published in a peer-reviewed journal. Included studies underwent screening and full text review before inclusion. A thematic analysis was performed using pre-determined overarching themes: (i) surgical training and education, (ii) patient education and engagement, and (iii) operative planning and surgical practice. Where applicable, subthemes were generated.ResultsA total of 56 papers were included. Most research was low-grade with 88% (n = 49) of publications at or below level III evidence. No randomised control trials or systematic reviews were found. Most literature (86%, n = 48) explored 3D reconstruction within operative planning. These were divided into subthemes of pre-operative (77%, n = 43) and intra-operative guidance (9%, n = 5). Few papers reported on surgical training and education (14%, n = 8), and were evenly subcategorised into virtual reality simulation (7%, n = 4) and anatomical teaching (7%, n = 4). No studies utilising 3D modelling for patient engagement and education were found.ConclusionThe use of 3D reconstruction is in its infancy in oesophagogastric surgery. The quality of evidence is low and key themes, such as patient engagement and education, remain unexplored. Without high quality research evaluating the application and benefits of 3D modelling, oesophagogastric surgery may be left behind.

Patient perspectives on key symptoms and preferences for follow-up after upper gastro-intestinal cancer surgery

PurposeLong-lasting symptoms and reductions in quality of life are common after oesophago-gastric surgery. Post-operative follow-up has traditionally focussed on tumour recurrence and survival, but there is a growing need to also identify and treat functional sequelae to improve patients’ recovery.MethodsAn electronic survey was circulated via a British national charity for patients undergoing oesophago-gastric surgery and their families. Patients were asked about post-operative symptoms they deemed important to their quality of life, as well as satisfaction and preferences for post-operative follow-up. Differences between satisfied and dissatisfied patients with reference to follow-up were assessed.ResultsAmong 362 respondents with a median follow-up of 58 months since surgery (range 3–412), 36 different symptoms were reported as being important to recovery and quality of life after surgery, with a median of 13 symptoms per patient. Most (84%) respondents indicated satisfaction with follow-up. Satisfied patients were more likely to have received longer follow-up (5-year or longer follow-up 60% among satisfied patients vs 27% among unsatisfied, p < 0.001). These were also less likely to have seen a dietitian as part of routine follow-up (37% vs 58%, p = 0.005).ConclusionThis patient survey highlights preferences regarding follow-up after oesophago-gastrectomy. Longer follow-up and dietician involvement improved patient satisfaction. Patients reported being concerned by a large number of gastrointestinal and non-gastrointestinal symptoms, highlighting the need for multidisciplinary input and a consensus on how to manage the poly-symptomatic patient.