INTRODUCTION:Optimal care pathways (OCP) were developed in Australia as a framework to define quality and timeliness targets. The 2022 National Pancreatic Cancer Roadmap highlighted a paucity of population-level data on pancreatic cancer management in Australia, such that compliance with OCP targets is uncertain. This study used real-world data to compare pancreatic cancer care in Victoria, Australia, against OCP targets. METHODS:Data collected on pancreatic cancer patients between January 2016 and July 2025 were extracted from the PURPLE registry for five Victorian tertiary hospitals. Care processes and timeliness outcomes were compared with OCP benchmarks. RESULTS:1878 patients were identified, with a median age of 70 years. At diagnosis, 41% had metastatic disease and 69% were ECOG performance status 0-1. Median interval from diagnosis to surgery was 20 days (OCP benchmark ≤ 28 days) with 60% of patients operated on within the timeframe, and to adjuvant therapy 55 days with 88% of patients receiving chemotherapy within the OCP benchmark of ≤ 84 days. However, just 33% received neoadjuvant chemotherapy, and 38% received palliative chemotherapy within the 28-day timeframe for commencing systemic treatment. Palliative care referral occurred in 65% of patients with advanced disease and 61% were discussed at a multidisciplinary meeting. Marked inter-site variation was evident across metrics. CONCLUSION:In Victoria, Australia, pancreatic cancer care variably met OCP targets. Real-world registry data can identify domains of care where performance is strong and highlight opportunities for process improvement and resource optimisation. Where OCP targets are rarely achieved, these findings support review of their real-world feasibility.

RATIONALE AND OBJECTIVES:Utilizing a fully automated AI-generated body composition analysis (BCA) from PDAC staging computed tomography (CT) imaging to discover predictive imaging biomarkers for overall survival (OS). MATERIAL AND METHODS:Routine PDAC staging CTs (07/2012-12/2020) and clinicopathological data (Eastern Cooperative Oncology Group (ECOG) performance status, resection status, chemotherapy, age, CA19-9, Charlson Comorbidity Index, BMI) from four tertiary centers were collected retrospectively. Using a 3:1 split (training:holdout), we fitted Cox regression OS using every possible combination of 7 clinicopathological and 9 BCA variables: skeletal muscle index (SMI), area and density of total muscle compartment (TMC), skeletal muscle (SM), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and selected the combination with the lowest information complexity (ICOMP). The added value of BCA was calculated by comparing the BCA model with the base model (without BCA variables). RESULTS:Analysis included 472 PDAC patients (213 female, mean age 67.9 ± 11.5 years, resectable n = 170, unresectable n = 106, metastatic n = 196). Four clinicopathological (ECOG, resection status, chemotherapy, CA19-9) and 5 BCA variables (SMI, SM density, VAT density, TMC area, VAT area) were selected. Decreased SM density (myosteatosis) and increased VAT density showed strong association with OS (p = 0.0094 and 0.0019, respectively). The BCA model showed superior performance compared to the base model in all subgroups (AUC: resectable 0.76 versus 0.70, unresectable 0.76 versus 0.69, and metastatic 0.80 versus 0.75). CONCLUSION:BCA-identified myosteatosis and increased VAT density to be predictive imaging biomarkers for OS in all PDAC subgroups, potentially adding value to upfront risk stratification.

Hepatic artery aneurysms (HAAs) are a rare type of splanchnic artery aneurysm. Our understanding is limited given the rarity of incidence. Rupture on presentation has a high mortality rate. We report the case of a 71-year-old woman who presented with a ruptured aberrant left HAA and subsequent cardiac arrest. She had risk factors of hypertension and was a long-term smoker. Post imaging-guided diagnosis and emergent multi-disciplinary discussion with the interventional radiology team, she underwent surgical resection of the aneurysm. Her recovery was unremarkable with gradual resolution of hepatic dysfunction and no residual post-arrest deficits. This case provides insight into the challenges of HAA anatomy and decision-making regarding surgical versus endovascular management and techniques.

BACKGROUND:Culturally and/or linguistically diverse (CALD) patients have unique health needs and may face multiple barriers when accessing healthcare. This study explored the association between of CALD status on treatment received and outcomes for patients with pancreatic cancer. METHODS:Data were extracted from the multi-site PURPLE Pancreatic cancer Translational Registry between January 2016 and April 2023. Registry data was supplemented by country of birth and preferred language data from linkage with hospital administrative datasets. CALD status was defined by being born overseas in a non-main English-speaking country and/or having a preferred language other than English. Descriptive statistics were used to analyse demographic data. Survival analysis was conducted using Kaplan-Meier estimates to generate survival curves, with comparisons assessed via the log-rank test. Moreover, univariable and multivariable Cox proportional hazards regression were employed. RESULTS:Of 1796 patients with pancreatic cancer enrolled at seven participating institutions, 1451 (80.8%) had their CALD status determined; with 661 (46%) identified as CALD. The CALD population were older (median age 72 vs. 68 years; P < 0.001), with a worse performance status (Eastern Cooperative Oncology Group score > 1: 20 vs. 13%, P = 0.004) and a greater number of comorbidities (Charlson Comorbidity Index > 3: 55 vs. 43%, P < 0.001). The use of neoadjuvant therapy in resectable/borderline resectable disease was similar. However, fewer CALD patients proceeded to curative-intent surgery following neoadjuvant therapy (30% vs. 51%, P = 0.041). In the metastatic setting, a higher proportion of CALD patients were offered best supportive care (50% vs. 41%; P = 0.021). Overall, there were no significant differences identified in the progression-free, recurrence-free or overall survival for CALD patients with pancreatic cancer across all stages of disease. CONCLUSIONS:CALD status was associated with multiple adverse prognostic factors (age, PS, comorbidities), which likely impacted differences in treatment received and challenges analysis of the independent impact of CALD status on outcomes. Notably, however, there were no striking differences by CALD status in treatment delivered or survival outcomes.

INTRODUCTION:Low phospholipid associated cholelithiasis (LPAC) is associated with variants of the adenosine triphosphate-binding cassette subfamily B, member 4 (ABCB4) gene and is characterized by reduced phosphatidylcholine secretion into bile, impairing the formation of micelles and thus exposing bile ducts to toxic bile acids and increasing cholesterol saturation. LPAC is present in 1% of patients with gallstones and post-cholecystectomy pain is common in this group. LPAC is an under-appreciated cause of post-cholecystectomy pain. The aim of this study is to assess a cohort of patients with post-cholecystectomy pain to identify those with clinical features suggesting that further investigations for LPAC would be beneficial. METHODS:A retrospective chart review was performed of the first 2 years of post-operative follow-up for all patients under 40 years of age undergoing cholecystectomy for symptomatic gallstones at a tertiary centre between January 2016 and December 2017. RESULTS:258 patients under the age of 40 underwent a cholecystectomy. 50 patients (19.4%) reported abdominal pain post-cholecystectomy. Five patients (1.9%) fulfilled the criteria for suspected LPAC. Family history of gallstones was documented in 33 of 258 (12.8%) of cases. Obstetric history was obtained in 69 of 197 (35%) female patients. None of the five patients identified above who satisfied the criteria of LPAC had the diagnosis of LPAC considered by their treating clinicians. CONCLUSION:LPAC is an under-recognized cause of post-cholecystectomy pain. Treatment can avoid long-term symptoms and complications. Clinicians should take a family history and obstetric history to alert them to the diagnosis of LPAC.

INTRODUCTION:People with Tuberculosis (TB) infection may present with glomerulonephritis (GN). The range of presentations, renal pathologies, and clinical outcomes are uncertain. Whether clinical features that establish if GN etiology is medication or TB related, and possible benefits of immunosuppression remain uncertain. METHODS:A scoping review was completed, searching MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and Conference Abstracts from Inception to December, 2023. The study population included patients with TB infection who developed GN and underwent renal biopsy. All data regarding presentation, patient characteristics, renal pathology, management of TB and GN, and outcomes were summarized. RESULTS:There were 62 studies identified, with 130 patients. These cases included a spectrum of presentations including acute kidney injury, nephrotic syndrome and hypertension, and a range of 10 different renal pathology diagnoses. Cases that included immunosuppression and outcomes ranged from complete remission to long-term dialysis dependence. The presence of granulomas (4/4, 100%), anti-glomerular basement membrane disease (3/3, 100%), amyloidosis (75/76, 98.7%), and focal segmental glomerulosclerosis (2/2, 100%) were specific for GN being TB-infection related. On the other hand, minimal change disease was specific for anti-TB therapy related (7/7, 100%). While patients with more aggressive forms of GN commonly were prescribed immunosuppression, this study was unable to confirm efficacy. Only rifampin or isoniazid were implicated in drug-associated GN. DISCUSSION:This study provides a clear rationale for renal biopsy in patients with TB and GN, and outlines predictors for the GN etiology. Thus, this study establishes key criteria to optimize diagnosis and management of patients with TB and GN.

Objective: To investigate the effect of early intervention with an electronic specialist-led ‘proactive’ model of care on glycaemic and clinical outcomes. Research Design and Methods: The STOIC-D Surgery randomised controlled trial was performed at the Royal Melbourne Hospital. Eligible participants were adults admitted to a surgical ward during the study with either known diabetes or newly-detected hyperglycaemia (at least one random blood glucose result ≥ 11.1 mmol/L). Participants were randomised 1:1 to standard diabetes care or the intervention consisting of an early consult by a specialist inpatient diabetes team utilising electronic tools for patient identification, communication of recommendations, and therapy intensification. The primary outcome was median patient-day mean glucose (PDMG). The key secondary outcome was incidence of healthcare-associated infection (HAI). Trial registration: ACTRN12620001303932. Results: Between February 12, 2021, and December 17, 2021, 1371 admissions met inclusion criteria with 680 assigned to early intervention and 691 to standard diabetes care. Baseline characteristics were similar between groups. The early intervention group achieved a lower median PDMG of 8.2 mmol/L (interquartile range [IQR] 6.9-10.0 mmol/L) compared with 8.6 mmol/L (IQR 7.2-10.3 mmol/L) in the control group for an estimated difference of -0.3 mmol/L (95% confidence interval [95%CI] -0.4 to -0.2 mmol/L, p<0.0001). The incidence of HAI was lower in the intervention group (77 [11%] vs. 110 [16%]), for an absolute risk difference of -4.6% (95%CI -8.2 to -1.0, p=0.016). Conclusions: In surgical inpatients, early diabetes management intervention with an electronic specialist-led diabetes model of care reduces glucose and HAI.

Background Surgery improves long-term survival for resectable, liver-only metastatic colorectal cancer (mCRC). With no consensus definition of “resectable” disease, decisions regarding resectability are reliant on the expertise and judgement of the treating clinician working in consultation with a multidisciplinary team (MDT). This study examines the clinical outcome versus initial assessment of resectability in an Australian population with mCRC. Patients and Methods Patients with liver-only mCRC diagnosed January 2009 to December 2022 were identified from the Treatment of Recurrent and Advanced Colorectal Cancer (TRACC) registry. Patients were classified based on prospectively documented treatment assessment as “resectable,” “potentially resectable,” or “unresectable.” The correlation between initial assessment of resectability and clinical outcome, and any impact of clinicopathologic factors were examined. Kaplan-Meier analysis assessed overall survival based on initial resectability assessment and resection status. Results Of 4437 patients with mCRC identified through TRACC, 1250 (28%) had liver-only disease at presentation, with 497 (43%), 277 (24%), and 374 (33%) classified as “unresectable,” “potentially resectable,” and “resectable,” respectively. In total, 516 (41%) ultimately underwent surgical resection, including 30 (6%) of the “initially unresectable,” 148 (53%) of the “potentially resectable,” and 338 (90%) of the “resectable” at a median of 9.5, 5.9, and 2.4 months from the diagnosis of liver metastases, respectively. Resection in the “unresectable” patient population was associated with younger age (mean age 63 vs. 69, P = .0006), better performance status (ECOG 0-1 100% vs. 74%, P = .0017), and fewer comorbidities (Charlson index 0-3 in 73% vs. 53%, P = .0296) compared with no resection. Median overall survival was longer for resected versus nonresected patients across all categories: “unresectable” (59.2 vs. 17.6 months, P < .0001), “potentially resectable” (57.2 vs. 22.8 months, P < .0001), and “resectable” (108 vs. 55 months, P < .0001). Conclusions This real-world study demonstrates the potential for “initially unresectable” patients to become surgical candidates following systemic therapy, more likely in younger and fitter patients, with overall excellent survival outcomes in resected patients. This highlights the value of routine, repeated MDT assessments for patients with liver-only disease who are continuing to respond to systemic therapy, even for those initially considered never to be surgical candidates.

11150 Background: With around 90% KRASmutation (mt) frequency, pancreatic ductal adenocarcinoma (PDAC) is considered the most RAS-addicted cancer. Despite guideline recommendations, genomic testing is not routine in all PDAC patients (pts) in Australia, due to unproven clinical impact. As more novel KRAS-direct therapeutics enter clinical trials, understanding the real-world frequency of individual mutations and prognostic significance, and facilitating trial recruitment are important goals, all of which can be supported by registry data. Methods: Data extracted from the PURPLE pancreatic cancer registry from 9 participating Australian cancer centres, between 2016-2022, was analysed to compare clinicopathological features, survival based on KRASmt status, and assess feasibility of the platform to identify and molecularly stratify patients for future clinical trials. Survival estimates were calculated using Kaplan-Meier curves and log-rank testing on SPSS (Macintosh v.29). Results: Of 721 PDAC routine care pts identified, next generation sequencing (NGS) was undertaken in 378/721 (52%). Median patient age was 68 years (range 52-83); 152 (40%) had resectable, 111 (29%) locally advanced and 115 (30%) metastatic disease. 57/378 (15%) were KRAS wildtype. Of 321 pts with a KRAS mt, codons 12,13, and 61 were the most common sites of mt, including G12D (45%), and G12V (30%), with lower frequencies of G12R (13%), Q61H (6%), G12A (3%), G12C (1%), and G13D (1%). Comparing KRAS wildtype to KRASmt pts, there was no difference in median age (68 vs 67, p=0.63), gender (male: 49% vs 60%, p=0.23), Charlson comorbidity index (p=0.30), or stage at first presentation (p=0.99). Overall KRAS wildtype pts were more likely to be ECOG PS 0 at diagnosis (p=0.01) and to receive at least 1 modality of treatment (p=0.004). For all pts, median overall survival (OS) in KRASwildtype versus KRAS mt pts was 29.0 months versus 19.7 months (p=0.007), and for the 115 metastatic pts 15.1 versus 10.4 months (p=0.28). Further analysis of the impact by disease stage and by individual RAS mt is underway. Conclusions: Registry based analysis informs understanding of KRAS mt status of PDAC in a community setting. Here, KRAS mt status was associated with worse OS outcomes, likely in part due to the association with ECOG PS and receiving less active treatment. With newer promising KRAS-targeted therapies becoming available in clinical trials, known RAS status will aid identification of trial candidates. The clinical utility of NGS and rationale for reflex testing in PDAC is increasing. Clinical Registry information (ACTRN12617001474347).

Background Pancreatic cancer incidence is increasing in younger populations. Differences between early onset pancreatic cancer (EOPC) and later onset pancreatic cancer (LOPC), and how these should inform management warrant exploration in the contemporary setting. Methods A prospectively collected multi-site dataset on consecutive pancreatic adenocarcinoma patients was interrogated. Patient, tumour, treatment, and outcome data were extracted for EOPC (≤50 years old) vs LOPC (>50 years old). Results Of 1683 patients diagnosed between 2016 and 2022, 112 (6.7%) were EOPC. EOPC more frequently had the tail of pancreas tumours, earlier stage disease, surgical resection, and trended towards increased receipt of chemotherapy in the curative setting compared to LOPC. EOPC more frequently received 1st line chemotherapy, 2nd line chemotherapy, and chemoradiotherapy than LOPC in the palliative setting. Recurrence-free survival was improved for the tail of pancreas EOPC vs LOPC in the resected setting; overall survival was superior for EOPC compared to LOPC across the resected, locally advanced unresectable and metastatic settings. Conclusions EOPC remains a small proportion of pancreatic cancer diagnoses. The more favourable outcomes in EOPC suggest these younger patients are overall deriving benefits from increased treatment in the curative setting and increased therapy in the palliative setting.

BACKGROUND:Patients with obstructive jaundice are conventionally described as hypocoagulable due to vitamin K malabsorption. However, associated underlying malignancy and synthetic liver dysfunction are mediators of hypercoagulability. The actual effect of biliary obstruction on the coagulation profile is not well characterised. This study aimed to define the coagulation status of patients with established biliary obstruction using rotational thromboelastometry (ROTEM). METHODS:This prospective cohort study, conducted in an Australian metropolitan hospital, included patients with a total bilirubin level of >150 umol/L and biliary obstruction on imaging. The primary outcome was the coagulation profile assessed using ROTEM. RESULTS:20 patients were included (median age 74.5 years), 15 were male and 17 had a malignant cause for biliary obstruction. The median bilirubin level was 209 umol/L (IQR: 175.0 umol/L - 255.8 umol/L). On ROTEM, all patients had normal or reduced clot formation times, and normal or increased maximum clot firmness. This confirmed all patients had a normal or hypercoagulable clotting profile, and none were auto-anticoagulated. Vitamin K administration before ROTEM did not vary the coagulation profile. DISCUSSION:Patients with established biliary obstruction and jaundice, predominantly due to malignancy, were normo or hypercoagulable. The belief that obstructive jaundice is associated with a hypocoagulable state should be questioned.

Background:This study explores the potential benefits of neoadjuvant chemotherapy in borderline resectable (BR) pancreatic adenocarcinoma. Despite neoadjuvant treatment (NAT) increasingly being utilised, uncertainty remains as to the optimal approach. Patients and methods:This study assessed clinical outcomes for 218 consecutive BR patients from the PURPLE registry. We compared initial surgery (IS) to NAT overall, and between different chemotherapy regimens. Results:Of 1314 non-metastatic patients enrolled, 218 (17%) were considered BR. Of 28 planned for IS, 11/28 (39%) had their tumour excised compared to 68/152 (45%) with NAT (P = 0.59). Among those who received NAT and were resected, 52/100 (52%) received FOLFIRINOX (P = 0.234) and 8/28 (29%) received nab-paclitaxel with gemcitabine (nabPGem). There was no difference in median overall survival (OS) [hazard ratio (HR) 0.72, P = 0.199] between pooled NAT versus IS. Neoadjuvant FOLFIRINOX was associated with improved R0 resection rates (26% versus 7%, P = 0.07) and lower perineural invasion (51% versus 82%, P = 0.02) compared to IS in resected specimens. Neoadjuvant FOLFIRINOX improved OS (HR 0.53, P = 0.02), with a 23% improvement in 2-year OS. There was no difference in survival outcomes between IS and nabPGem. Conclusions:The results of our study suggest that neoadjuvant FOLFIRINOX could improve R0 resection rate and OS compared to IS.

Introduction Blunt diaphragm injury (BDI) is an uncommon, potentially fatal consequence of blunt torso injury. While associations between BDI and other factors such as mechanism of injury or other injuries have been described elsewhere, little recent research has been done in Australia into BDI. The aims of this study were to determine the incidence rate of BDI in our centre, identify how it was diagnosed, determine rates of missed injury and identify predictive factors for BDI. The hypothesis was that patients with BDI would significantly differ to those without BDI. Methods All major trauma patients with blunt torso injuries at our Level 1 major trauma service from 2010 to 2018 were included. Data for patient demographics, other injuries, diagnosis and treatment of BDI were extracted. Patients with BDI were compared with patients without BDI in order to identify differences that could be used to predict BDI in future patients. Results Of 5190 patients with a blunt torso injury, 51 (0.98%) had a BDI at a mean age of 53 ± 19.6 years, and median Injury Severity Score (ISS) of 27(IQR 21–38.5) compared with 5139 patients with a mean age of 48.2 ± 20.7 years and median ISS of 21.9(IQR 14–26) who did not have a BDI. The diagnosis of BDI was made at CT ( n = 35), surgery ( n = 14) or autopsy ( n = 2). Blunt diaphragm injury was missed on index imaging for 11 of 43 patients (25.6%). On multivariate analysis, each point increase in ISS (OR 1.03, p = 0.02); rib fractures (OR 4.65, p = 0.004); splenic injury (OR 2.60, p = 0.004); and liver injury (OR 2.78, p = 0.003) were independently associated with BDI. Conclusion Injury Severity Score, rib fractures and solid abdominal organ injury increase the likelihood of BDI. In patients with these injuries, BDI should be considered even in the presence of normal CT findings.

Endoscopic Retrograde CholangioPancreatography (ERCP) remains a critical component of care for patients with biliary disease. Gallstone disease & pancreatitis are one of the leading presentations for emergency general surgical units in Australia accounting for between 12.8%–16.4% of presentations. Along with presentations with malignant jaundice, a significant proportion will require endoscopic sphincterotomy, sphincteroplasty, dilatation, stone extraction or stent placement. Access to ERCP in Australia is variable with most metropolitan hospitals providing out of hours ERCP access for emergency cases. Regional and rural centres, however, often have limited access, usually related to a lack of trained endoscopists, but also due to the cost and availability of duodenoscopes, disposable equipment, specialist nursing and imaging support. Many regional and remote centres rely on close connections with metropolitan services to enable the transfer of patients for ERCP but this can carry significant risks for patients with severe sepsis due to cholangitis, particularly due to the time taken to cover significant distances, as well as significant costs. Training opportunities are often competitive with the current requirement for recognition of training by the Conjoint Committee for Recognition of Training (CCRTGE) being satisfactory supervisor reports as well as the performance of 200 unassisted but supervised ERCPs with intact ampullary complexes along with 80 sphincterotomies and 60 stent placements. The CCRTGE has representatives from three parent bodies, The Royal Australasian College of Surgeons (RACS), The Royal Australasian College of Physicians (RACP) and the Gastroenterological Society of Australia (GESA) with equal representation of surgeons and physicians on the Committee. Combined with general surgical or post-fellowship training, recognition of training in ERCP will often take at least 2–3 years, even working in a high volume ERCP centre. In comparison to a gastroenterology trainee with concentrated access to endoscopy training, surgical trainees have many competing requirements to complete their General Surgical or post fellowship specialty training making completion of the ERCP requirements more difficult. Furthermore, access for surgical trainees to surgical ERCP lists is usually much easier than gastroenterology however states such as Victoria offer access to both with surgical access in metropolitan, regional & rural centres. In my time as Chair of the CCRTGE I became aware of the unequal access to ERCP training in Australia with active barriers in some states preventing surgeons from accessing or completing ERCP training. There is no published evidence that ERCP performed by a surgeon in Australia is inferior to that delivered by a gastroenterologist, but there is international evidence of equivalency. Hepatopancreaticobiliary (HPB) and upper gastrointestinal (UGI) fellows who may have already undertaken significant training may be unable to complete the requirements for recognition depending on the state in which they finish their training. Access to ERCP across regional and rural Australia also requires General Surgeons to be trained in ERCP. Dundee et al. have previously published 700 ERCP’s performed in a low-volume rural centre by a single ERCP trained general surgeon reporting safe and successful treatment outcomes. In this issue of the ANZ Journal of Surgery, Nestor et al. describe the management of 191 patients who underwent ERCP by an ERCP trained general surgeon in a 30 month period between January 2019 and July 2022 in a regional Queensland centre. Successful common bile duct cannulation occurred for 98.95%. of patients with acceptable complication rates that included four (2.09%) with pancreatitis, two duodenal perforations (1.05%), two sphincterotomy bleeds (1.05%) and two anaesthetic complications. There were no deaths reported. They were also able to report a significant cost saving from local treatment being delivered rather than incurring the $3500 cost for an aero-medical transfer. Partly due to a lack of access to ERCP for management of choledocholithiasis, laparoscopic trans-cystic exploration and laparoscopic choledochotomy are well established in Australia as an alternative management technique for choledocholithiasis. The ability to deliver surgical treatment, however, again relies on local expertise, equipment and training. Laparoscopic techniques however do not allow treatment for patients with severe sepsis from cholangitis or for the management of jaundice. I personally believe that it is critical that a proportion of HPB & UGI surgeons as well as regional & rural general surgeons have access to ERCP training for the provision of services across Australia and the evidence presented by Nester et al. supports that high-quality ERCP can be performed by general surgeons in the rural setting.

Victoria suffered three major waves during the first two years of the COVID-19 pandemic. Melbourne became the longest locked down city in the world at 267 days. This narrative review documents the chronological waves of COVID-19 in Victoria and key themes influencing the State-wide surgical response. In 2020, Victoria needed to secure supplies of personal protective equipment (PPE) and later, recognizing the importance of aerosol transmission, introduced a respiratory protection program to protect health care workers (HCWs) with fit-tested N-95 masks. It established routine preoperative PCR testing for periods when community prevalence was high and developed strategies to restrict elective surgery when hospital capacity was limited. In 2021, three short-term outbreaks were contained and eliminated whilst vaccination of HCWs and the vulnerable was taking place. A third major wave (Delta) occurred July to November 2021, succeeded by another involving the Omicron variant from December 2021. Planned surgery waiting list numbers, and waiting times for surgery, doubled between March 2020 and March 2022. In early 2022, almost 300 patients underwent surgery when infected with Omicron, with a low mortality (2.6%), though mortality was significantly higher in the unvaccinated (7.3% versus 1.4%). In conclusion, the Victorian response to COVID-19 involved tight state-wide social restrictions, contact tracing, furlough, escalating PPE guidance and respiratory protection. HCW infections were greatly reduced in 2021 compared with 2020. Pre-operative PCR testing gave confidence for emergency and urgent elective surgery to proceed during pandemic waves. Other elective cases were performed as health system capacity allowed, without compromising outcomes.

Supplementary Tables S1-S4.

Pancreatic acinar cell carcinoma (ACC) is a rare pancreatic neoplasm, often eluding clinicians because of the lack of diagnosis awareness and expert knowledge regarding clinical, radiological and pathological characteristics of ACC. Main differential diagnoses include pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumor (PNET) and accurate diagnosis is crucial to ensure optimal treatment and outcomes. This case of a 58-year old male illustrates the correlation between clinical, imaging, molecular histopathological and whole genome and transcriptome profiling that was required to diagnose and guide treatment of this complex pancreatic ACC.