Multi-cancer early detection test in symptomatic patients referred for cancer investigation in England and Wales (SYMPLIFY): a large-scale, observational cohort study

BACKGROUND

Analysis of circulating tumour DNA could stratify cancer risk in symptomatic patients. We aimed to evaluate the performance of a methylation-based multicancer early detection (MCED) diagnostic test in symptomatic patients referred from primary care.

METHODS

We did a multicentre, prospective, observational study at National Health Service (NHS) hospital sites in England and Wales. Participants aged 18 or older referred with non-specific symptoms or symptoms potentially due to gynaecological, lung, or upper or lower gastrointestinal cancers were included and gave a blood sample when they attended for urgent investigation. Participants were excluded if they had a history of or had received treatment for an invasive or haematological malignancy diagnosed within the preceding 3 years, were taking cytotoxic or demethylating agents that might interfere with the test, or had participated in another study of a GRAIL MCED test. Patients were followed until diagnostic resolution or up to 9 months. Cell-free DNA was isolated and the MCED test performed blinded to the clinical outcome. MCED predictions were compared with the diagnosis obtained by standard care to establish the primary outcomes of overall positive and negative predictive value, sensitivity, and specificity. Outcomes were assessed in participants with a valid MCED test result and diagnostic resolution. SYMPLIFY is registered with ISRCTN (ISRCTN10226380) and has completed follow-up at all sites.

FINDINGS

6238 participants were recruited between July 7 and Nov 30, 2021, across 44 hospital sites. 387 were excluded due to staff being unable to draw blood, sample errors, participant withdrawal, or identification of ineligibility after enrolment. Of 5851 clinically evaluable participants, 376 had no MCED test result and 14 had no information as to final diagnosis, resulting in 5461 included in the final cohort for analysis with an evaluable MCED test result and diagnostic outcome (368 [6·7%] with a cancer diagnosis and 5093 [93·3%] without a cancer diagnosis). The median age of participants was 61·9 years (IQR 53·4-73·0), 3609 (66·1%) were female and 1852 (33·9%) were male. The MCED test detected a cancer signal in 323 cases, in whom 244 cancer was diagnosed, yielding a positive predictive value of 75·5% (95% CI 70·5-80·1), negative predictive value of 97·6% (97·1-98·0), sensitivity of 66·3% (61·2-71·1), and specificity of 98·4% (98·1-98·8). Sensitivity increased with increasing age and cancer stage, from 24·2% (95% CI 16·0-34·1) in stage I to 95·3% (88·5-98·7) in stage IV. For cases in which a cancer signal was detected among patients with cancer, the MCED test's prediction of the site of origin was accurate in 85·2% (95% CI 79·8-89·3) of cases. Sensitivity 80·4% (95% CI 66·1-90·6) and negative predictive value 99·1% (98·2-99·6) were highest for patients with symptoms mandating investigation for upper gastrointestinal cancer.

INTERPRETATION

This first large-scale prospective evaluation of an MCED diagnostic test in a symptomatic population demonstrates the feasibility of using an MCED test to assist clinicians with decisions regarding urgency and route of referral from primary care. Our data provide the basis for a prospective, interventional study in patients presenting to primary care with non-specific signs and symptoms.

FUNDING

GRAIL Bio UK.

Breast cancer liver metastases: systematic review and time to event meta-analysis with comparison between available treatments

INTRODUCTION

The current gold standard treatment for breast cancer liver metastases (BCLM) is systemic chemotherapy and/or hormonal therapy. Nonetheless, greater consideration has been given to local therapeutic strategies in recent years. We sought to compare survival outcomes for available systemic and local treatments for BCLM, specifically surgical resection and radiofrequency ablation.

METHODS

A review of the PubMed (MEDLINE), Embase and Cochrane Library databases was conducted. Data from included studies were extracted and subjected to time-to-event data synthesis, algorithmically reconstructing individual patient-level data from published Kaplan-Meier survival curves.

FINDINGS

A total of 54 studies were included, comprising data for 5,430 patients (surgery, n=2,063; ablation, n=305; chemotherapy, n=3,062). Analysis of the reconstructed data demonstrated survival rates at 1, 3 and 5 years of 90%, 65.9% and 53%, respectively, for the surgical group, 83%, 49% and 35% for the ablation group and 53%, 24% and 14% for the chemotherapy group (p<0.0001).

CONCLUSION

Local therapeutic interventions such as liver resection and radiofrequency ablation are effective treatments for BCLM, particularly in patients with metastatic disease localised to the liver. Although the data from this review support surgical resection for BCLM, further prospective studies for managing oligometastatic breast cancer disease are required.

Examining the benefit of graduated compression stockings in the prevention of hospital-associated venous thromboembolism in low-risk surgical patients: a multicentre cluster randomised controlled trial (PETS trial)

INTRODUCTION

Hospital-acquired thrombosis (HAT) is defined as any venous thromboembolism (VTE)-related event during a hospital admission or occurring up to 90 days post discharge, and is associated with significant morbidity, mortality and healthcare-associated costs. Although surgery is an established risk factor for VTE, operations with a short hospital stay (<48 hours) and that permit early ambulation are associated with a low risk of VTE. Many patients undergoing short-stay surgical procedures and who are at low risk of VTE are treated with graduated compression stockings (GCS). However, evidence for the use of GCS in VTE prevention for this cohort is poor.

METHODS AND ANALYSIS

A multicentre, cluster randomised controlled trial which aims to determine whether GCS are superior in comparison to no GCS in the prevention of VTE for surgical patients undergoing short-stay procedures assessed to be at low risk of VTE. A total of 50 sites (21 472 participants) will be randomised to either intervention (GCS) or control (no GCS). Adult participants (18-59 years) who undergo short-stay surgical procedures and are assessed as low risk of VTE will be included in the study. Participants will provide consent to be contacted for follow-up at 7-days and 90-days postsurgical procedure. The primary outcome is the rate of symptomatic VTE, that is, deep vein thrombosis or pulmonary embolism during admission or within 90 days. Secondary outcomes include healthcare costs and changes in quality of life. The main analysis will be according to the intention-to-treat principle and will compare the rates of VTE at 90 days, measured at an individual level, using hierarchical (multilevel) logistic regression.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Camden and Kings Cross Research Ethics Committee (22/LO/0390). Findings will be published in a peer-reviewed journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN13908683.

P-P44 Clinical outcomes of consecutive patients undergoing distal pancreatectomy over the last decade at a high volume tertiary pancreatic surgery unit

Background

Distal pancreatectomy (DP) enables resection of lesions in the body and tail of the pancreas.  Over the past decade, the Laparoscopic approach has become frequently employed.  There remains scarce outcome data available following laparoscopic distal pancreatectomy over a long time period from high volume centres. Postoperative pancreatic fistula (POPF) remains the main source of morbidity and mortality after DP. The causes of POPF are multifactorial and poorly understood.  The optimal method of pancreatic stump closure is still debated with variation in clinical practice.

Methods

All patients that underwent distal pancreatectomy at a UK tertiary pancreatic surgery centre between January 2011 and January 2021 were identified and clinical outcomes examined. Patients undergoing completion pancreatectomies were excluded. Clinical, pathological and surgical data for the included patients was retrospectively collected from the electronic patient record.  Clinically significant POPF was defined as Grade B or C as per the ISGPF guidelines. For stapled stump closure, the Compression Index (CI) was calculated using closed staple height (mm) divided by the pancreatic thickness (mm). High and low CI was defined around the median.

Results

233 patients (n = 90 open and n = 143 laparoscopic) were included in the final analysis. The laparoscopic approach was associated with comparable morbidity and significantly lower blood loss, shorter operative time and shorter length of stay. There were no significant differences in age, sex, final histology, closure technique, or ASA Score of 3 or more amongst patients with clinically relevant POPF (CR-POPF). The POPF group had a significantly higher BMI, drain duration and readmission rate. CI data was available for 78 cases (range 0.04-0.21). There was no significant difference in low vs high CI for patients with CR-POPF.

Conclusions

Laparoscopic distal pancreatectomy is associated with favourable clinical outcomes in this series. Stapled vs sutured closure of the pancreatic stump offered equivocal outcomes with relation to POPF. POPF continues to have a significant impact on a clinical recovery as evident from longer drain duration and high readmission rates. Further research is required to try to establish methods for reducing the incidence of POPF after distal pancreatectomy.

P-P29 The glycated haemoglobin (HbA1c) test is not a predictor of pancreatectomy specific complications or survival

Background

The glycated haemoglobin (HbA1c) test is a venous blood test used as a diagnostic test for diabetes mellitus and to monitor glucose control in patients known to have diabetes. The test has been recommended by National Institute for Health Care Excellence (NICE) clinical guidelines in the pre-operative setting since 2016. The purpose of testing is to reduce perioperative morbidity and mortality by optimising management of blood glucose levels in the perioperative period. The aim of this study was to assess the prognostic value of HbA1c in pancreatic cancer patients treated with pancreaticoduodenectomy.

Methods

This is a retrospective analysis of a prospectively managed database of pancreatic resections at a single institution from January 2016 to December 2020. Included patients had confirmed pancreatic adenocarcinoma and underwent a pancreaticoduodenectomy with preoperative measurement of their HbA1c. Patients who were already prescribed insulin were excluded. Demographic data, survival, operative and perioperative details were collected. Included patient records were assessed for the incidence of postoperative complications in accordance with International Study Group of Pancreatic Surgery guidelines for pancreatic fistula, delayed gastric emptying and post pancreatectomy haemorrhage. An HbA1c greater than 41 was deemed elevated.

Results

There were 145 patients who met the inclusion criteria. The HbA1c level was normal in 101/145 (70%) and elevated in 44/45 (30%). The postoperative pancreatic fistula rate was 18% in the patients with a normal HbA1c and 23% in those with elevated HbA1c (p = 0.499). The rate of delayed gastric emptying was 21 and 23% in the patients with normal and elevated HbA1c respectively. There were five relaparotomies overall, one of these patients had an elevated preoperative HbA1c. There were no perioperative deaths. Overall survival was 31months (95%CI 27-35) with a normal preoperative HbAlc and 32months (95%CI 27-38) if elevated.

Conclusions

There is little doubt that the preoperative HbA1c is helpful in the package of preoperative assessment tests to optimise patients for surgery. However, the preoperative HbA1c level in patients planned for pancreaticoduodenectomy is not predictive of pancreaticoduodenectomy specific complications such as postoperative pancreatic fistula, delayed gastric emptying, relaparotomy or mortality. In addition, long-term overall survival is not influenced by an elevated preoperative HbAlc.

P-P47 Impact of neoadjuvant chemotherapy on postoperative pancreatic fistula in patients undergoing pancreaticoduodenectomy

Background

Pancreatic adenocarcinoma (PDAC) is one of the most lethal tumours with a five-year survival rate of less than 7% for all stages. However, current evidence suggests neoadjuvant treatment (NAT) may have survival benefits in those with borderline resectable disease. Post-operative pancreatic fistula (POPF) is a potential complication after pancreaticoduodenectomy (PD) and is associated with long-term morbidity. The rate of developing POPF post-PD in those receiving NAT is currently unclear.

Methods

Patients undergoing PD (both classical and pylorus-preserving) were identified from a prospectively collected local database. Those who received NAT prior to surgery were identified, and case-matched controls based on their age and sex, were then identified from the database. Post-operative drain amylase levels were used to compare POPF between groups. For the analysis, drain amylase levels greater than three times the upper limit of normal at day five were consistent with biochemical POPF.

Results

A total of 34 patients (14 females, 20 males) underwent PD after receiving NAT at our unit from January 2013 to July 2021. The median age was 66 years at the time of surgery. Two patients (5.9%) in the NAC group had biochemical leaks on day five compared to 4 (11.8%) in the case-matched control group (p = 0.7).

Conclusions

Our early data suggest a possibility of a lower incidence of biochemical POPF in those undergoing PD post-NAT. Aetiology on the development of POPD post-NAT is still unclear, and this requires further study and long-term follow up.  

P-P30 Outcomes from resection of pancreatic metastases and non-neuroendocrine, non-pancreatic tumours

Background

Isolated metastatic disease within the pancreas is an uncommon finding. The potentially higher perioperative risk and low incidence of resectable metastases has limited the development of evidence based guidelines for pancreatic metastectomy. However, reports in the literature suggest a considered approach to resecting patients with limited disease, favourable tumour type and a significant disease free interval. The aim of this study was to examine the indications and outcomes of pancreatic resection for metastatic disease and non-pancreatic, non-neuroendocrine malignancy at a high-volume pancreatic surgery centre.

Methods

This is a retrospective analysis of a prospectively managed database of pancreatic resections for metastatic disease or primary non-pancreatic, non-neuroendocrine tumours at a single institution. Data collected and analysed included patient demographics, operative details and peri-operative outcomes, subsequent survival and mode of recurrence.

Results

Records of 711 patients who underwent pancreatic resection were examined. 21 consecutive patients met the inclusion criteria, representing 3% of the unit’s throughput. The perioperative morbidity and mortality were 33% and 0% respectively. Overall survival was 86months (95%CI 63-107) for renal cell carcinoma and 64months for other tumours.

Conclusions

When coupled with the low morbidity and mortality rates of a high-volume pancreatic surgery centre using careful patient selection, pancreatic metastectomy has the potential to result in good long-term survival. Recent improvement in the efficacy of systemic therapies, particularly for renal cell carcinoma and melanoma contribute to the utility of resection and to the improved survival of patients.

P-P57 The first experience of intraoperative radiotherapy for pancreatic cancer in the UK

Background

Intraoperative radiotherapy (IORT) involves giving a targeted single fraction of high dose radiation to the resection bed. The main advantages are exclusion of vulnerable structures from the radiation field and ability to direct the electron beam to threatened margins.  IORT in pancreatic cancer is not new, with Japanese centres reporting series from the 1970s. Early reports were exciting, suggesting that IORT was useful in reducing visceral pain, achieving local control and improving survival in locally advanced and unresectable patients. However, paucity of randomised trials in the ensuing decades has limited its widespread adoption.

Methods

With funding from the PLANETS charity (www.planetscharity.org), University Hospitals Southampton acquired a Mobetron 2000 linear accelerator (IntraOp, USA) in 2016. Testing was done at the National Physical Laboratory (Teddington, UK) over two months to collect beam data and ensure consistency in treatment delivery. Staff training included visits to the Heidelberg Cancer Centre and several dry runs. Inclusion criteria were: (i) patients with pancreatic head adenocarcinomas; (ii) threatened vascular margins; (iii) WHO performance status 1-2; (iv) no evidence of distant metastasis.

Results

Nineteen patients had pancreaticoduodenectomy (traditional or pylorus preserving) combined with IORT. Median age was 66 (42-81) years. Median ASA grade was 2 (2-3). 16/19 had locally advanced pancreatic cancer and 18/19 had neoadjuvant chemotherapy. Median IOERT dose was 15 (10-15) Gy, energy 7.5 (6-12) MeV, to a mean depth of 1.6 +/- 0.8 cm, with median cone size 5 (4-6) cm and bevel angle 15 (0-30) degrees. All tumours were pT1-T3 and 10/19 had positive regional nodes. 10/19 were R1 resections, with 4/19 specimens exhibiting vascular invasion and 6/19 perineural invasion. Mean operating time (including IOERT) was 534 +/- 77 min. Median length of stay was 8.5 (6-41) days. 30-day mortality was zero. 6/19 patients had post-operative complications (Clavien-Dindo 1-2 only), with clinically detectable pancreatic fistula in 1/19.

Conclusions

This is the first UK experience of IORT for pancreatic cancer, showing that this treatment modality is safe and feasible. With the appropriate expertise, an IORT service can be implemented within 12 months of acquiring the Mobetron system. We hope that these data will encourage other UK and European HPB units to consider setting up regional IORT services, such that larger scale prospective trials can be initiated to demonstrate its efficacy.

P-P13 Long-term outcome after portal vein resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matched analysis

Background

Portal vein resection (PVR) with pancreaticoduodenectomy (PD) is often performed to achieve clear margins for patients with vascular involvement in pancreatic ductal adenocarcinoma (PDAC). However, there is evidence to suggest that patients undergoing PVR often have more advanced cancers, therefore the impact of PVR on survival and recurrence remains unclear. The aim of this study is to assess overall (OS) and recurrence free (RFS) survival in patients who underwent PVR during PD, with particular attention to margin positivity.

Methods

A retrospective analysis was performed on 638 patients who underwent PD during a 12-year period. Exclusion criteria included PD for non-PDAC tumours, neoadjuvant chemotherapy or intra-operative radiotherapy. 374 patients were included in the study (90 PVR and 284 non-PVR). Patient characteristics and histopathological factors associated with OS and RFS were then evaluated using univariate and multivariate Cox regression analyses. 270 patients (90 PVR and 180 non-PVR), were matched by propensity score based on perineural invasion, pT and pN staging. The Kaplan-Meier method was used to calculate survival and log-rank tests.

Results

Resection margin positivity was associated with shorter OS and RFS (p &lt; 0.0001), and the superior mesenteric vein (SMV) margin was the most significant risk factor for survival on competing risks analysis. Absent adjuvant chemotherapy, nodal metastasis and margin positivity were independent risk factors for OS and RFS on multivariate analysis. PVR was associated with higher intra-operative blood loss (p = 0.009), but was not associated with increased length of stay, complications or readmissions. PVR patients had increased pT staging, nodal metastasis and perineural invasion, however, there was no difference in OS (p = 0.551) or RFS (p = 0.256) between PVR and non-PVR after propensity matching.

Conclusions

Positive resection margins are associated with shorter survival times, and the SMV margin is the most significant prognostic indicator for overall survival and recurrence compared to other margins. PVR is a relatively safe procedure, however, it does not achieve the intended survival benefits of complete margin clearance. The impact on survival for margin positivity, particularly the SMV margin, and nodal metastasis should be considered when making decisions with regards to vein resection and adjuvant treatments.

Intraoperative radiotherapy for pancreatic cancer: implementation and initial experience

This article reports on the first series of patients to receive intraoperative radiotherapy for pancreatic cancer in the UK. The data suggest that this treatment modality is feasible and safe, laying a platform for collaborative multicentre trials to better assess efficacy.

Clinical relevant pancreatic fistula after pancreatoduodenectomy: when negative amylase levels tell the truth

Drain Amylase level are routinely determined to diagnose pancreatic fistula after Pancreatocoduodenectomy. Consensus is lacking regarding the cut-off value of amylase to diagnosis clinically relevant postoperative pancreatic fistulae (POPF). The present study proposes a model based on Amylase Value in the Drain (AVD) measured in the first three postoperative days to predict a POPF. Amylase cut-offs were selected from a previous published systematic review and the accuracy were validated in a multicentre database from 12 centres in 2 countries. The present study defined POPF the 2016 ISGPS criteria (3 times the upper limit of normal serum amylase). A learning machine method was used to correlate AVD with the diagnosis of POPF. Overall, 454 (27%) of 1638 patients developed POPF. Machine learning excluded a clinically relevant postoperative pancreatic fistulae with an AUC of 0.962 (95% CI 0.940-0.984) in the first five postoperative days. An AVD at a cut-off of 270 U/L in 2 days in the first three postoperative days excluded a POPF with an AUC of 0.869 (CI 0.81-0.90, p < 0.0001). A single AVD in the first three postoperative days may not exclude POPF after pancreatoduodenectomy. The levels should be monitored until day 3 and have two negative values before removing the drain. In the group with a positive level, the drain should be kept in and AVD monitored until postoperative day five.

Metabolic syndrome is a predictor of all site and liver-specific recurrence following primary resection of colorectal cancer: Prospective cohort study of 1006 patients

INTRODUCTION

Large epidemiological studies have demonstrated the link between metabolic syndrome and cancer development, including colorectal cancer. However, the influence of metabolic syndrome on disease progression is less well studied, particularly in the post-surgical setting. This study investigates the effect of metabolic syndrome on colorectal cancer recurrence (all-site and liver-specific) after curative surgery for Stage I-III disease.

MATERIALS AND METHODS

Consecutive patients who underwent curative resection for Stage I-III colorectal cancer in a single UK centre were prospectively recruited. Disease-free and overall survival with metabolic syndrome as a factor, were determined using the Kaplan-Meier technique. Hazard ratios for all-site and liver-specific recurrence were determined using univariable and multivariable Cox-regression models.

RESULTS

1006 patients were recruited and followed up for a median of 50 months (IQR 30-67). 177 patients (17.6%) met the criteria for metabolic syndrome. 245 patients (25.4%) developed recurrence, 161 (16.0%) of these had liver recurrence. The presence of metabolic syndrome was associated with a reduction in disease-free survival from 69 to 58 months (p < 0.001) and overall survival from 74 to 61 months (p < 0.001). Metabolic syndrome was an independent predictor of all-site (HR 1.76; p < 0.001) and liver-specific (HR 1.74; p = 0.01) recurrence.

CONCLUSION

Metabolic syndrome is a predictor of all-site and liver-specific recurrence after primary resection of stage I-III colorectal cancer.

Compression stockings in addition to low-molecular-weight heparin to prevent venous thromboembolism in surgical inpatients requiring pharmacoprophylaxis: the GAPS non-inferiority RCT

BACKGROUND

Patients admitted to hospital for surgery are at an increased risk of venous thromboembolism. Pharmaco-thromboprophylaxis and mechanical prophylaxis (usually graduated compression stockings or intermittent pneumatic compression) have been shown to reduce the incidence of venous thromboembolism. The evidence base supporting the National Institute for Health and Care Excellence's recommendation for the use of graduated compression stockings for venous thromboembolism prevention in the UK has recently been challenged. It is unclear if the risks and costs associated with graduated compression stockings are justified for deep-vein thrombosis prevention in moderate- and high-risk elective surgical inpatients receiving low-dose low-molecular-weight heparin pharmaco-thromboprophylaxis.

OBJECTIVES

The primary objective was to compare the venous thromboembolism rate in elective surgical inpatients at moderate or high risk of venous thromboembolism who were receiving either graduated compression stockings and low-dose low-molecular-weight heparin (standard care) or low-dose low-molecular-weight heparin alone (intervention).

DESIGN

This was a pragmatic, multicentre, prospective, non-inferiority, randomised controlled trial.

SETTING

This took place in secondary care NHS hospitals in the UK.

PARTICIPANTS

Patients aged ≥ 18 years who were assessed to be at moderate or high risk of venous thromboembolism according to the NHS England venous thromboembolism risk assessment tool (or the trust equivalent based on this form) and who were not contraindicated to low-molecular-weight heparin or graduated compression stockings were deemed eligible to take part.

INTERVENTIONS

Participants were randomised 1 : 1 to either low-molecular-weight heparin or low-molecular-weight heparin and graduated compression stockings.

MAIN OUTCOME MEASURES

The primary outcome measure was venous thromboembolism up to 90 days after surgery. A combined end point of duplex ultrasound-proven new lower-limb deep-vein thrombosis (symptomatic or asymptomatic) plus imaging-confirmed symptomatic pulmonary embolism. Secondary outcomes included quality of life, compliance with graduated compression stockings and low-molecular-weight heparin during admission, and all-cause mortality.

RESULTS

A total of 1905 participants were randomised and 1858 were included in the intention-to-treat analysis. A primary outcome event occurred in 16 out of 937 (1.7%) patients in the low-molecular-weight heparin-alone arm compared with 13 out of 921 (1.4%) patients in the low-molecular-weight heparin plus graduated compression stockings arm. The risk difference between low-molecular-weight heparin and low-molecular-weight heparin plus graduated compression stockings was 0.30% (95% confidence interval -0.65% to 1.26%). As the 95% confidence interval did not cross the non-inferiority margin of 3.5% (p < 0.001 for non-inferiority), the results indicate that non-inferiority of low-molecular-weight heparin alone was shown.

LIMITATIONS

In total, 13% of patients did not receive a duplex ultrasound scan that could have detected further asymptomatic deep-vein thrombosis. However, missing scans were balanced between both trial arms. The subpopulation of those aged ≥ 65 years assessed as being at a moderate risk of venous thromboembolism was under-represented in the study; however, this reflects that this group is under-represented in the general population.

CONCLUSIONS

For elective surgical patients at moderate or high risk of venous thromboembolism, administration of pharmaco-thromboprophylaxis alone is non-inferior to a combination of pharmaco-thromboprophylaxis and graduated compression stockings. These findings indicate that graduated compression stockings may be unnecessary for most elective surgical patients.

FUTURE WORK

Further studies are required to evaluate whether or not adjuvant graduated compression stockings have a role in patients receiving extended thromboprophylaxis, beyond the period of hospital admission, following elective surgery or in patients undergoing emergency surgical procedures.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13911492.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 69. See the NIHR Journals Library website for further project information.

Implementation of enhanced recovery after surgery for pancreatoduodenectomy increases the proportion of patients achieving textbook outcome: A retrospective cohort study

BACKGROUND

Enhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as 'textbook outcome' (TBO).

METHODS

In a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012-January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009-April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test.

RESULTS

The two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005).

CONCLUSION

Implementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS.

Graduated compression stockings as adjuvant to pharmaco-thromboprophylaxis in elective surgical patients (GAPS study): randomised controlled trial

OBJECTIVES

To investigate whether the use of graduated compression stockings (GCS) offers any adjuvant benefit when pharmaco-thromboprophylaxis is used for venous thromboembolism prophylaxis in patients undergoing elective surgery.

DESIGN

Open, multicentre, randomised, controlled, non-inferiority trial.

SETTING

Seven National Health Service tertiary hospitals in the United Kingdom.

PARTICIPANTS

1905 elective surgical inpatients (≥18 years) assessed as being at moderate or high risk of venous thromboembolism were eligible and consented to participate.

INTERVENTION

Participants were randomly assigned (1:1) to receive low molecular weight heparin (LMWH) pharmaco-thromboprophylaxis alone or LMWH pharmaco-thromboprophylaxis and GCS.

OUTCOME MEASURES

The primary outcome was imaging confirmed lower limb deep vein thrombosis with or without symptoms, or pulmonary embolism with symptoms within 90 days of surgery. Secondary outcome measures were quality of life, compliance with stockings and LMWH, lower limb complications related to GCS, bleeding complications, adverse reactions to LMWH, and all cause mortality.

RESULTS

Between May 2016 and January 2019, 1905 participants were randomised. 1858 were included in the intention to treat analysis (17 were identified as ineligible after randomisation and 30 did not undergo surgery). A primary outcome event occurred in 16 of 937 (1.7%) patients in the LMWH alone group compared with 13 of 921 (1.4%) in the LMWH and GCS group. The risk difference between the two groups was 0.30% (95% confidence interval -0.65% to 1.26%). Because the 95% confidence interval did not cross the non-inferiority margin of 3.5% (P<0.001 for non-inferiority), LMWH alone was confirmed to be non-inferior.

CONCLUSIONS

For patients who have elective surgery and are at moderate or high risk of venous thromboembolism, administration of pharmaco-thromboprophylaxis alone is non-inferior to a combination of pharmaco-thromboprophylaxis and GCS. These findings indicate that GCS might be unnecessary in most patients undergoing elective surgery.

TRIAL REGISTRATION

ISRCTN13911492.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC.

METHODS

This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred.

RESULTS

There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63).

CONCLUSIONS

The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

IL-12 and IL-15 induce the expression of CXCR6 and CD49a on peripheral natural killer cells

INTRODUCTION

Murine hepatic NK cells exhibit adaptive features, with liver-specific adhesion molecules CXCR6 and CD49a acting as surface markers.

METHODS

We investigated human liver-resident CXCR6+ and CD49a+ NK cells using RNA sequencing, flow cytometry, and functional analysis. We further assessed the role of cytokines in generating NK cells with these phenotypes from the peripheral blood.

RESULTS

Hepatic CD49a+ NK cells could be induced using cytokines and produce high quantities of IFNγ and TNFα, in contrast to hepatic CXCR6+ NK cells. RNA sequencing of liver-resident CXCR6+ NK cells confirmed a tolerant immature phenotype with reduced expression of markers associated with maturity and cytotoxicity. Liver-resident double-positive CXCR6 + CD49a+ hepatic NK cells are immature but maintain high expression of Th1 cytokines as observed for single-positive CD49a+ NK cells. We show that stimulation with activating cytokines can readily induce upregulation of both CD49a and CXCR6 on NK cells in the peripheral blood. In particular, IL-12 and IL-15 can generate CXCR6 + CD49a+ NK cells in vitro from NK cells isolated from the peripheral blood, with comparable phenotypic and functional features to liver-resident CD49a+ NK cells, including enhanced IFNγ and NKG2C expression.

CONCLUSION

IL-12 and IL-15 may be key for generating NK cells with a tissue-homing phenotype and strong Th1 cytokine profile in the blood, and links peripheral activation of NK cells with tissue-homing. These findings may have important therapeutic implications for immunotherapy of chronic liver disease.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.