Upper gastrointestinal training in the UK and Ireland: a Roux Group Study

INTRODUCTION

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I.

METHODS

A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability.

RESULTS

A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage.

CONCLUSIONS

Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

P-OGC14 Global Level of Harm Upper Gastrointestinal (GLEOHUG) – a multinational gastric cancer cross- sectional appraisal

Background

Gastric cancer (GC) is the 5^th most common malignancy and remains one of the major causes of worldwide cancer-related deaths. COVID-19 pandemic has had a significant impact on the provision of cancer care. This study aims to overview the global standpoint of gastric cancer patients (GCP) during the first year of the pandemic.

Methods

The Upper Gastrointestinal Surgeons (TUGS), within its Global Level of Harm Project, designed an online cross-sectional survey to assess how gastric cancer patient’s management changed during the first year of the pandemic. The questionnaire included 33 questions about expertise, kind of health system, hospital organization and screening policies, personal protective equipment (PPE), change in patient’s characteristics, preoperative, operative and postoperative management of GCP.

Results

There were 209 participants from 178 centres & 50 countries). Results showed: most hospitals (88,18%) had restricted areas for COVID-19 patients; 53.58% of surgeons were redeployed; most frequent COVID-19 screening method was PCR (78,82%) & chest CT-scan (25,62%), and 55.98% lack full PPE. Preoperative management: 43.16% noted reduction in multidisciplinary teams (MDT) meetings; 28,42% increase in cT2 or higher GCP; 34,74% increase in metastatic (M1) GCP; 26,84% increase in patients receiving definitive palliative treatment; 23,68% note increase in frail patients; 50% increase in waiting list time; and 41,58% faced problems in the provision of oncological treatment. Operative management: 54,50% decrease in elective gastrectomies; 29,10% increase in urgent/semi-urgent gastrectomies; 37,04% decrease in the number of minimally-invasive gastrectomies (MIG); & 18,52% increase in the number of palliative surgeries. Postoperative management: 16,48% increase in the overall complication rate (OCR); 12,64% increase in the number of Clavien-Dindo 3 or higher complications; 8,13% increase in the leak rate; increase in pulmonary infections (26,79%) and bowel obstruction (2,39%); 44,51% note postoperative COVID-19; 15,38% increase in 30-days mortality; 23,08% mortality due to COVID-19 infection; 17,58% increase in the need for adjuvant treatment. Most patients were postoperatively assessed either through a face-to-face consultation or a hybrid approach.

Conclusions

COVID-19 pandemic has affected gastric cancer management by decreased frequency of MDT’s, higher clinical-stage migration and fuelled frailty. The pandemic increased waiting list time, the number of urgent and palliative surgeries, OCR, Clavie-Dindo 3 or higher complications, leak rate, and pulmonary infections. There was a noticeable high rate of postoperative COVID-19 infection and associated mortality. Further multicentric studies are warranted to affirm these findings.

231 Breast Lymphedema After Breast Conservative Surgery; An Up-To-Date Systematic Review

Background

While arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema,

Aim:

We aimed to provide a systematic review to help avoiding or management of breast lymphoedema

Method

The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative and surgery to search Embase database. All papers published in English were included with no exclusion date limits

Results

A total of 2155 female patients were included in this review; age ranged from 26 to 90. Mean BMI was 28.4, most of the studies included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as body mass index (BMI), breast size, tumour size, tumour site, type of surgery and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including Manual lymphatic drainage (MLD), self-massaging, compression bras or Kinesio taping.

Conclusions

Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.

499 Upper GI Surgical Clinic Referrals, Can We Improve Patient Experience?

Introduction

With increasing pressure on NHS to deal with long waiting lists, solutions to reduce waiting times are imperative. In the era of the COVID-19 pandemic, we need to reshape the way we look into Outpatient clinic appointments.

Aim

To review all clinic referrals to UGI surgical clinic and highlight any potential pathways that can improve waiting times and patient experience.

Method

Patients referred to UGI clinic over 2 months were collected from Iclip, EPR and EDM. Post-discharge appointments and DNA’s were excluded. Data collected included time from referral to clinic, type of referral, symptoms, investigations, potential pathway, first clinic outcome, and appropriateness of referral.

Results

Total of 147 referrals analyzed. Time from referral to clinic appointment is 51 days. GP referrals represented 73% while the rest from consultant colleagues. The most common symptoms were biliary colic and GORD. OGD and PH manometry were the most common investigations requested. The most common first outcome was pre investigate and clinic follow up. Two potential pathways identified are Biliary colic and GORD pathway. 90% of referrals were appropriate.

Conclusions

Biliary colic pathway and GORD pathway are 2 potential pathways that can cut off waiting times for clinic appointments and improve patient experience in outpatient clinics.