The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single-centre, observational cohort study

INTRODUCTION

The prevalence and complications of biliary disease increase with age. Frailty has been associated with adverse outcomes in the hospital setting. We describe the prevalence of frailty in older patients hospitalised with benign biliary disease and its association with duration of hospital stay, and 90-day and 1-year mortality.

METHODS

We performed a retrospective cohort study of patients aged 75 years and over admitted with acute biliary disease between 17 September 2014 and 20 March 2017. Clinical Frailty Scale (CFS) score was recorded on admission.

RESULTS

We included 200 patients with a median age of 82 (75-99) years, 60% were female; 154 (77%) were independent for personal activities of daily living (ADLs) and 99 (49.5%) for instrumental ADLs. Cholecystitis was the most common diagnosis (43%) followed by cholangitis (36%) and pancreatitis (21%). Ninety-nine patients were non frail (NF; CFS 1-4) and 101 were frail (F; CFS 5-9). Some 104 patients received medical treatment only. Surgery was more common in NF patients (11% vs F 2%), percutaneous drainage more frequently performed in F patients (15% vs NF 5%) and endoscopic cholangiopancreatography was similar in both groups (F 32% vs NF 31%). Frailty was associated with worse clinical outcomes in F vs NF: functional deconditioning (34% vs 11%), increased care level (19% vs 3%), length of stay (12 vs 7 days), 90-day mortality (8% vs 3%) and 1-year mortality (48% vs 24%).

CONCLUSIONS

Half of patients in our cohort were frail and spent longer in hospital, were less likely to undergo surgery and were less likely to remain alive at 1 year after discharge.

V-021 REPORT OF AN ACQUIRED INTERCOSTAL HERNIA REPAIR USING A BILAYER MESH

Aim

A 53-year-old male underwent a T10/11 discectomy with partial removal of the right T9 rib. 10 years later, he developed an acquired painful intercostal hernia, worsened by leaning against the defect. CT imaging demonstrated an 8cm hernial defect containing the posterior lobe (segment VII) of the liver with a loss of integrity of the diaphragm.

Methods

Open surgical repair though the original incision was undertaken, with the patient in the left lateral position. The hernia was entirely reducible in this position.

Results

The liver was replaced into the peritoneal cavity, the hernial sac and the weakness at the postero-lateral edge of the diaphragm were then identified. The edges of the hernial sac were dissected off the ribs. An intraperitoneal mesh (SymbotexTM; Medtronic, Lyon) was cut to size, placed, and fixed to the undersurface of the ribs, with a 5cm overlap obtained medially and laterally. Care was taken to avoid damaging the neurovascular bundle and breach of the pleural cavity was not observed.

A bridging mesh was then used to reinforce the repair (VersatexTM; Medtronic, Lyon) with fixation to the ribs using ethibond sutures and cyanoacrylate glue (Glubran®; Viareggio). The repair was checked by Valsalva manoeuver prior to wound closure.

Post operative pain control was achieved using intercostal nerve block and patient-controlled analgesia. A post-operative chest x-ray did not demonstrate a pneumothorax. The patient was discharged on postoperative day 2.

Discussion

The patient experienced no serious postoperative sequelae and was pain free with no hernia at 30 days post-surgery.

871 Liver Transplant for Colorectal Liver Metastases: A Systematic Review and Meta-Analysis of Proportions

Introduction

Colorectal liver metastases were historically considered a contraindication to liver transplantation, but dismal outcomes for those with metastatic colorectal cancer and advancements in liver transplantation (LT) have led to a renewed interest in the topic. We aim to compare the current evidence for liver transplantation for non-resectable colorectal liver metastases (NRCLM) with the current standard treatment of palliative chemotherapy reported in literature – 5-year survival rate <10%.

Method

A systematic review and meta-analysis of proportions was conducted following screening of MEDLINE, EMBASE, SCOPUS and CENTRAL for studies reporting liver transplantation for colorectal liver metastases. Post-operative outcomes measured included 1-, 3- and 5-year survival, overall survival, disease-free survival, and complication rates.

Results

Three non-randomised studies met the inclusion criteria, reporting a total of 48 patients receiving LT for NRCLM. Survival at 1-, 3- and 5-years was 83.3-100%, 58.3-80% and 50-80% respectively with no significant difference detected (p = 0.22, p = 0.48, p = 0.26). Disease free survival was 35-56% with the most common site of recurrence being lung. Thirteen out of fourteen deaths were due to disease recurrence.

Conclusions

Although current evidence suggests a survival benefit conferred by LT in NRCLM compared to palliative chemotherapy, the ethical implications of organ availability and allocation demand rigorous justification. Eight registered clinical trials will report on 300 more patients undergoing LT for NRCLM over the next 10 years: concomitant improvements in the management of patients following liver resection and of palliative chemotherapy regimens is paramount.

138 Endovascular Hepatic Artery Stents in The Modern Management of Post-Pancreatectomy Haemorrhage

Aim

Post-operative haemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on endovascular hepatic artery stents in the management of post-pancreatectomy haemorrhage.

Method

This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcome, contextualized by the clinical course of the denominator population. International Study Group for Pancreas Surgery (ISGPS) terminology was used for post-pancreatectomy haemorrhage.

Results

Sixty-seven (15%) had post-operative haemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; two-proportions test). Post-operative pancreatic fistulas were more frequent in the post-operative haemorrhage group (P = 0.029; two-proportions test). The median (IQR) delay between surgery and haemorrhage was 5 (2-14) days. Twenty-six required intervention comprising re-operation alone in 12, embolization alone in 5 and endovascular hepatic artery stent deployment in 5. Four further patients underwent multiple interventions with two having stents. Endovascular stent placement achieved initial haemostasis in 5 (72%). Follow-up was for a median (IQR) of 199 (145-400) days post-stent placement. In two patients the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 (8-22) days.

Conclusions

This study shows that in the specific setting of post-pancreatoduodenectomy haemorrhage with either a short remnant GDA bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important haemostatic option but is associated with a high risk of subsequent graft occlusion.

720 Pringle Versus Selective Hepatic Vascular Exclusion in Major Hepatectomy: A Systematic Review and Meta-Analysis

Aim

Mortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. Multiple techniques have been developed in an attempt to minimise blood loss by occluding hepatic inflow and outflow. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion compared to a Pringle manoeuvre in hepatic resection reduces rates of morbidity and mortality.

Method

A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL, SCOPUS and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Intra- and post-operative outcome measures were investigated. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

Results

Five studies were identified including two randomized controlled trials and three observational studies reporting a total of 2,198 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, patients requiring blood transfusion, air embolism, warm ischaemia time, liver failure and multi-organ failure when performing SHVE compared to a Pringle manoeuvre. Rates of hepatic vein rupture and post-operative haemorrhage remained the same. Performing SHVE resulted in a significantly longer operation time.

Conclusions

Performing SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle manoeuvre, although may prolong operating time. The results of this meta-analysis are based on a few high-quality studies where tumours were adjacent to major vessels. Further RCTs are required to validate these results and determine the best technique for hepatic vascular control in this patient cohort.

717 Roux-En-Y Versus Single Loop Reconstruction in Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Aim

Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

Method

A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

Results

Fourteen studies were identified including four randomized controlled trials (RCTs) and 10 observational studies reporting a total of 2 031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

Conclusions

Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomized studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

513 THE INFLUENCE OF FRAILTY ON OUTCOMES FOR OLDER ADULTS ADMITTED TO HOSPITAL WITH BENIGN BILIARY AND PANCREATIC DISEASE

Introduction

The prevalence and complications of biliary disease increase with age. We describe the prevalence of frailty in older patients hospitalised with benign biliary and pancreatic disease and establish its association with mortality and duration of hospital stay.

Methods

Prospective observational cohort study of patients aged 75 years and over admitted with a diagnosis of acute biliary disease to a surgical hospital unit between 17/09/2014 and 20/03/2017. Clinical Frailty Scale (CFS) score was recorded on admission.

Results

We included 200 patients with a median age of 82 (75–99), 60% females, 89% lived in their homes, 154 (77%) were independent for personal and 99 (49.5%) for instrumental ADLs, 95% mobilised independently, 17.5% had memory impairment and 8% low mood. Acute cholecystitis was the most common diagnosis (43%) followed by acute cholangitis (36%) and acute pancreatitis (21%). 99 patients were non-frail (NF = CFS 1–4) and 101 were frail (F = CFS ≥5). 104 patients received medical treatment only. Surgery was more common in non-frail (F 2% vs. NF 11%), percutaneous drainage more frequently carried out in frail patients (15% vs. NF 5%) and endoscopic cholangiopancreatography (ERCP) was similar in both groups (F 32%vs. NF 31%). Frailty was associated with worse clinical outcomes in F vs. NF: functional deconditioning (34% vs. 11%), increased care level (19% vs 3%), length of stay (12 vs. 7 days), 90-day (8% vs. 3%) and 1 year-mortality (48% vs. 24%).

Conclusion

Half of patients in our cohort of older adults hospitalised with acute biliary disease were frail. Higher scores of frailty are associated with increased mortality. Compared with non-frail patients, individuals living with frailty were less likely to undergo surgical treatment, spent longer in hospital and were less likely to remain alive at 12 months after hospital discharge.

Totally extraperitoneal repair for the 'sportsman's groin' via 'the Manchester Groin Repair': a comparison of elite versus amateur athletes

BACKGROUND

Surgery has a recognised role in the treatment of 'sportsman's groin'. This study hypothesises that elite athletes have a superior advantage in both pre- and post-op rehabilitation and therefore will present and resume sporting activities quicker.

METHODS

A retrospective analysis on a secure database of athletes presenting with groin pain that underwent surgery for 'inguinal disruption'. All data were explored via appropriate descriptive statistics and comparisons made between elite and amateur athletes.

RESULTS

All patients were male (n = 144). The median age 33 years (range 14-72). The median return to sporting activity was 4.5 weeks (range 2.0-16.0) with one amateur athlete being unable to return to sporting activity. Using the mean of both sides, a comparison of VAS pain scores at pre-operative and 1 month post-operative time points showed a significant reduction (p < 0.001). Comparing 'elite' versus 'amateur' athletes, significant differences were seen in patient age (median 26 vs 40 years; p < 0.001), lead time to clinic presentation (median 62.0 vs 111.5 days; p = 0.004), and time to return to sporting activity (4 vs 5 weeks; p = 0.019). Additional MRI findings within the groin girdle were found in 89 patients (66.4%) and 34 patients (23.6%) had an MRI finding within the adductor tendon.

CONCLUSION

The Manchester Groin Rrepair is an effective surgical management for 'inguinal disruption'. Elite athletes present quicker and return to sport sooner. Given the prevalence of other findings, a multidisciplinary approach to the 'sportsman's groin' is required.

Complicated liver echinococcosis: 30 years of experience from an endemic area

BACKGROUND AND AIMS

Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis.

MATERIAL AND METHODS

A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed.

RESULTS

Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated.

CONCLUSIONS

Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Clinical features of colonic diverticular disease

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.