Abstract Background Neoadjuvant chemo/radiotherapy (NAT) is the treatment of choice for borderline resectable/ locally-advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Current preoperative imaging modalities (CT/MRI) and biomarkers lack sensitivity to predict response following NAT. The aim of this study was to evaluate preoperative PETCT and CA19-9 in predicting NAT response and survival. Methods A retrospective analysis of consecutive patients who underwent NAT for BR/LA PDAC between January 2013 and January 2023 was performed. Clinicopathological characteristics, treatment, and outcome were analysed. Pre- and post-NAT CA 19-9 and PETCT findings were correlated with resectability and pathological response. Overall survival (OS) and disease-free survival (DFS) comparisons were performed using log-rank model and Kaplan–Meier analysis. Results Tumour response following completion of NAT was evaluated in 87 (BR, n=58 and LA, n=29) patients with a median age of 73.3 years (47-87 years). FOLFIRINOX alone (93%, n=81) was mostly used as chemotherapy versus gemcitabine/nab-paclitaxel (7%). Post NAT, 51% of patients had biochemical response (CA19-9>50% decrease) and 48% had metabolic response on PETCT. Overall, 31(35%) individuals (BR, n=27 and LA, n=4) underwent complete resection with 81% achieving R0 status. After univariate analysis, pre-operative PETCT metabolic response (HR, 2.1; 95% CI, 1-4.3) was the only pre-operative predictor of resectability and correlated significantly with pathological response (P<0.003). In multivariate analysis, pre-operative metabolic response was the best performing predictor for resectability (P<0.001), pathological response (P<0.003), DFS (HR, 1.34; 95% CI, 1.3-1.9) and OS (HR, 1.45; 95% CI, 1.2-1.8). NAT patients had a median OS of 19 months, improving to 36 months for patients receiving NAT followed by curative surgery (HR 0.3; 95% CI, 0.1-0.56. P < .0001). Conclusions PETCT metabolic response appears to be highly predictive of resectability, pathological response and survival following NAT for BR/LA PDAC. An adequate staging of PDAC and re-assessment of the tumour after neoadjuvant therapy using PETCT would allow the multidisciplinary team to choose the most appropriate treatment for the patient.

Introduction Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones. Methods Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Results Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. Conclusions The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Purpose: Pancreatoduodenectomy (PD) patients are disproportionately affected by malnutrition, which is associated with poor postoperative outcomes. The aim of this study was to report current nutritional practice and opinion after pancreatoduodenectomy (PD) in the United Kingdom and Ireland (UK&I) and to understand whether a trial would be feasible.

This study defines core patient descriptors in perforated peptic ulcer research. Background Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research. Methods Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings. Results Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history. Conclusion This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

Abstract Background In line with the NCRI framework, appropriate staging and classification of pancreatic cancer, with particular relevance to vascular involvement, is essential to ensure patients are offered all potential treatment options both at diagnosis and post-neoadjuvant therapy. This pan-specialty national collaborative consensus project, supported by PCUK,AUGIS,PSGBI,RCSEng,NCRI,RCR and BSGAR, aimed to develop a succinct radiological reporting template to allow a more consistent and standardized means of detailing all clinically-relevant aspects of pancreatic cancer, which, in addition to the aforementioned benefits, will allow more efficient MDT review, improved ability to audit national practice, and optimized clinical trial design. Methods In stage one, a core group of stakeholders from surgery, radiology and oncology was formed to establish current practice and determine the optimal data-set for a template. This included a blinded radiological validation study of established templates in use (Beth-Israel, PROTRACT and Glasgow proformas), and national survey of consultant surgeons on the PSGBI mailing list. Thereafter, consensus meetings led to the development of a provisional template. In stage two, representatives from surgery, radiology and oncology at all UK HPB units attended a consensus meeting to discuss and finalise the first official template draft, with subsequent trial utilisation in clinical practice. Results In stage one, the radiological assessment highlighted a significant variation in reporting of vascular involvement, with 100% concordance in only 30% of cases. Within the surgeon survey, amongst various tumour-related factors, most notably a significant majority preferred a specific range of degrees of vascular involvement, and specific information regarding tributary involvement and associated narrowing/occlusion/thrombosis. Both processes, and subsequent national consensus meetings in stage two, helped establish the ideal factors required in a template with respect to usability, clinical relevance, applicability and IT-factors, resulting in the generation of the PACT-UK proforma that will be presented at the congress. Conclusions This pan-specialty collaborative consensus project has successfully produced the first nationally-developed pancreatic cancer radiological reporting template. In stage three, the PACT-UK group aim to continue trialing the proforma nationally, with upcoming workshops facilitated by RCR/BSGAR to ensure buy-in from radiologists at all HPB units. Further representation from all units is welcomed, with the philosophy that template data-points can and will continue to evolve on the basis of ongoing feedback from consensus meetings, and following the development of more aggressive surgical techniques and novel neoadjuvant therapies. Plans for the use of PACT-UK within national audit and clinical trials is under-way.

Aims Endoscopic ultrasound guided choledochoduodenostomy (EUS-CDD) with electrocautery enhanced lumen apposing metal stents (EC-LAMS) has recently emerged as a viable option in the management of patients with malignant distal biliary obstruction (MDBO). We conducted a multi-centre collaboration from the UK and Ireland with an aim to analyse the pooled efficacy, safety and long term outcomes of EUS-CDD for treatment of MDBO.

A 44-year-old gentleman with stage III (T4N1M0) unresectable pancreatic adenocarcinoma at the uncinate process underwent percutaneous image guided Irreversible Electroporation (IRE). At day-1 post IRE the patient developed severe abdominal pain and had computed tomography for assessment of his symptoms. Computed tomography showed severe duodenal wall thickening with local inflammatory changes and was reported as duodenal infarction based on imaging features. Following conservative management with better pain management, both the clinical symptoms and imaging features resolved uneventfully. This case has highlighted severe duodenal swelling seen in patients post IRE for locally advanced pancreatic cancer may mimic duodenal infarction and is an important differential diagnosis to ensure appropriate clinical management.

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.

Introduction: Despite making up more than half of new doctors, women are underrepresented in most surgical specialties. Various reasons have been suggested for this including issues with work-life balance, discrimination and a lack of female role models in the specialty. We sought to quantify the extent of gender discrimination in leadership roles in surgical societies in the UK. Methods: All major Surgical Specialty Organisations were identified via the Royal College of Surgeons Website. Leadership and committee information was collected via organisation websites on 5th September 2018. All societies were then contacted requesting data including total membership, their stage of training and the gender split. Results: Of the twenty-four organisations contacted, eighteen were able to provide data. Women accounted for 11.8% (2446/20 803) of consultant and 34.3% (5267/15 366) of trainee members. 2/24 presidents; 3/26 of vice presidents; 18.1% (39/215) of executive committees and 13.5% (49/364) of wider committee members were female. Thirty-four committee members were not included as they were not surgeons (23 female; 11 male). Discussion: Despite accounting for 27% of the surgical workforce and indeed 24% of surgical society members, women account for only 2 of 24 Presidents and 18.1% (39/215) of the executive committees of surgical societies in the UK. Action should be taken so women are fairly represented in leadership roles in surgical societies with one of the benefits being more visible role models for prospective female surgeons.

Introduction: Incisional hernia is a complication of midline or transverse abdominal approach. We present a comparative case-matched study that compares the outcomes of midline to transverse incision for major pancreatic surgery in terms of incisional hernia rates, wound complications and length of hospital stay. Methods: From February 2007 to December 2014, 321 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. 180 were matched on a 1:1 basis (90 midline, 90 transverse) according to age, gender, tumour size, pancreatic duct diameter and histopathological diagnosis. Comparison between groups was performed on intention-to-treat basis. Results: The midline and transverse groups were comparable for age (65 vs. 64.3 years, p = 0.89), gender distribution (p = 0.92) and tumour size (2.0 vs. 2.2 cm, p = 079). There was no significant difference between midline and transverse groups in incisional hernias at one year (14 vs. 15, p = 0.89), 30-day mortality (2 vs. 2, p = 0.92), mortality after one year (21 vs. 19, p = 0.43) and median length of hospital stay (10 vs. 12 days, p = 0.15). However, the wound infection rate was higher in the transverse group (18 vs 10, p = 0.04). Conclusion: There is no statistical difference in the rate of incisional hernia for midline vs. transverse approach. The rate of wound infection appears to be higher in the transverse group but the decision about the incision should be dictated by the patient's disease and anatomy and the surgeon's discretion.

Introduction: The aim of this study was to assess the effectiveness of Leeds Pathology Protocol (LEEPP) in stratifying patients after periampullary cancer resections. Methods: Clinicopathological features, including exact site and multifocality of margin involvement, and survival were collated from a prospective series of 422 pancreatoduodenectomies (PD) for pancreatic (n = 222), ampullary (n = 98) and bile duct cancer (n = 102). The impact of histopathological variables on overall survival was analysed. Data represent median (range). Results: The overall R1 rate was 78% (n = 331); was higher in pancreatic (82.9%) and bile duct (70.2%) cancer and significantly lower in ampullary cancer (27%). There was a significant difference in OS between R0 and R1 resections in the entire cohort. The median OS in patients with R1 and R0 resection margins were 14.2 (10–18.3) months and 38.2 (9–55) months respectively; (p = 0.004). The overall 5-year actual survival rates for the R1 vs. R0 resections were 18 vs 52%; (p = 0.001). Margin positivity was often multifocal, the posterior margin being most frequently involved. Of clinical interest, the median OS in ampullary cancer subgroup with R1 and R0 resection margins were 22 (18–29) months and 41 (17–55) months respectively; (p = 0.001). Conclusion: A periampullary cancer patient confirmed with an R0 resection using LEEPP has a 50% 5-year survival rate.

Background: This study aims to evaluate the consent process and recovery expectations that patients go through before undergoing major pancreatic surgery. Methods: Patients undergoing elective pancreatic resections were identified from the weekly operative schedules. Patients (n = 30) were given a questionnaire to complete the day before discharge. Inclusion criteria included patients who had a Whipple's procedure (n = 20) or distal pancreatectomy (n = 10). Operative details, length of stay, and person gaining consent were noted. The patient was then asked to assess the consent process and how their expectations on recovery time changed before and after consent, and before discharge. Results: Mean length of stay was 11 ± 6 days. Consent was obtained in the clinic in 60% (n = 18) of patients and, of them, 89% (n = 16) had consent obtained from a consultant. Consultants obtained consent from 17 (57%) patients in total, and most patients (80%) had met the person taking consent before. Most patients (93%) thought enough information had been given to them and 29 (97%) patients said they were encouraged to ask questions. Expected recovery time was given to 80% of patients consented in clinic compared to 50% of patients consented elsewhere. Recovery time expectations changed in 11 (37%) patients before and after consent process. Expectations changed again just before discharge in 8 (27%) patients. Conclusions: The majority of patients feel that enough information is given to them during the consent process before major surgery, however, expected recovery times was not explored in all patients. Consenting in the clinic appears to be the most satisfactory location.

AIMS: To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC).METHODS AND MATERIALS: Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution.RESULTS: One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC.CONCLUSION: In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery. (C) 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

BACKGROUND By 2033, the number of people aged 85 years and over in the UK is projected to double, accounting for 5% of the total population. It is important to understand the surgical outcome after a pancreatic resection in the elderly to assist decision making. METHODS Over a 9-year period (from January 2000 to August 2009), 428 consecutive patients who underwent a pancreatic resection were reviewed. Data were collected on mortality, complications, length of stay and survival. Patients were divided into two groups (younger than 70 and older than 70 years old) and outcomes were analysed. RESULTS In all, 119 (27.8%) patients were ≥ 70 years and 309 (72.2%) patients were < 70 years. The median length of stay for the older and younger group was 15 days (range 3-91) and 14 days (range 3-144), respectively. The overall mortality was 3.4% in the older group and 2.6% in the younger group (P = 0.75). The older cohort had a cumulative median survival of 57.3 months (range 0-119), compared with 78.7 months (range 0-126) in the younger cohort (P < 0.0001). In patients undergoing a pancreatic resection for ductal adenocarcinoma and cholangiocarcinoma there was a significant difference in survival with P-values of 0.043 and 0.003, respectively. For ampullary adenocarcinoma, the older group had a median survival of 47.1 months compared with 68.3 months (P = 0.194). CONCLUSION Results from this study suggest that while elderly patients can safely undergo a pancreatic resection and that age alone should not preclude a pancreatic resection, there is still significant morbidity and mortality in the octogenarian subgroup with poor long-term survival with the need for quality-of-life assessment.

Introduction Groove pancreatitis (GP) is a form of chronic segmental pancreatitis. Due to increased awareness of the condition, a greater number of cases have been reported in recent years. Clinical symptoms are heterogeneous, with abdominal pain and gastric outlet obstruction considered the most common, and can mimic pancreatic adenocarcinoma. Most of the published literature is represented by small series. Aim of the study is to describe our experience in the management of this condition. Methods From January 2005 to December 2011, 47 patients with GP were treated in our Unit. 33 males (M:F=2.3:1); mean age was 50 (31–84), average number of hospital admissions was 4 (0–20), mean hospital stay was 10 days (1–82). Eight patients needed HDU/ICU support. Aetiology was alcohol in 41 (87%) and 13 were abstinent for more than 6 months at last follow-up. Amylase was elevated (3xN) on admission in 22. The most common feature was abdominal pain (n=40, 85%) and 50% (n=20) required daily use of opioids. Gastric outlet obstruction (n=7), jaundice (n=11) and acute renal failure (n=5) were less frequent. Exocrine insufficiency was present in 23 (49%). 13 had a dilated pancreatic duct (>5 mm) and 6 developed portal hypertension. Median follow-up was 34 months. Results There were five deaths, one due to GP. 29 patients were treated conservatively; 11 required enteral feeding. 4 had ERCP and biliary stenting, two of which subsequently underwent biliary reconstruction. One patient had a pancreatic stent and then a Berne9s procedure. Endoscopic drainage for pseudocyst (n=2), cholecystectomy (n=6) for sludge/stones, gastric bypass (n=3), Puestow procedure (n=1), Whipple9s operation (n=4, two of which later required thoracoscopic splanchnicectomy—TS), TS (n=3), celiac plexus block (n=2) were the other interventions. Overall 28 (66%) patients are well with no or occasional use of analgesia, six patients still experience recurrent hospital admissions and 8 require regular use of analgesia but with improved symptoms. Conclusion The majority of GP is caused by alcohol excess. GP can be effectively treated conservatively and pain (the most common symptom) managed with simple analgesia. Despite good support the majority remain addicted to alcohol. Radical surgery should be reserved for complex cases, as it is not always effective for pain relief, and when there is a diagnostic dilemma. Competing interests None declared.