Introduction: Evidence supports early enteral nutrition in patients who have undergone pancreaticoduodenectomy (PD). Where enteral nutrition is inadequate patients can be supplemented or primarily fed via the parenteral route. There is a paucity of data on the effect of route of feeding on survival. Method: At a single tertiary hepatopancreatobiliary center, we screened all patients who had pancreaticoduodenectomy (PD) from June 2014 - September 2019. Data on nutritional status and receipt of pancreatic enzyme replacement therapy (PERT) was extracted. The parenteral group (PG) were patients receiving ³72 hours of total parenteral nutrition (TPN) consecutively within the first ten days postoperatively. The enteral group (EG) were patients receiving nutrition through the enteral route (orally, nasojejunal or nasogastric tube). Primary outcome was survival. Cox regression analysis was used to clarify the main determinants of survival. Results: A total of 144 patients had PD; EG (n=98): enteral (n=26), enteral + PERT (n=72) & PG (n=46), parenteral (n=5), parenteral + PERT (n=41). Median survival: EG vs PG was 1172 vs 489 days respectively (95% CI 0.208-0.576, p 0.0004), PERT vs no PERT 532 vs 813 days respectively (95% CI 0.439-0.973, p 0.047). Factors associated with improved survival included enteral nutrition (p<0.001), no lymphovascular invasion (p<0.001), R0 resection (p=0.038), earlier T stage (p<0.001) and no adjuvant chemotherapy (p= 0.004). Conclusion: Enteral nutrition was associated with improved short-term survival over Parenteral nutrition. However due to poor overall survival in PD it is yet unknown whether route of nutrition has any long-term survival benefit.

Abstract Aim Since first laparoscopic liver surgery (LLR) in 1991, no literature to compare Incisional hernia (IH) incidence between LLR and open Resection (OLR). This is the first comparative study Material and methods Single centre retrospective review of Colorectal Liver Metastasis resections between 2011 till 2018. The primary end point is developing IH related to liver resection. Incidence of IH was compared between LLR and OLR. Factors including Age, Gender, Diabetes Mellitus, Steroid intake, Pre-op Creatinine and Albumin, Previous Liver resection ASA score were compared between both groups. Subcutaneous and peri-renal fat thickness measured as indicative of fat distribution. Numeric results presented in Mean±SD. SPSS 20 (IBM, Armonk, USA) used for statistical analysis. p ≤ 0.05 was considered statistically significant Results 247 procedures with follow-up 41 ± 29 Months. IH was observed in 48 case (19.4%). Incidence was 10%, 19% at 1, 3 years respectively (Kaplan-Meier). 87 case (35%) had LLR and 160 (65%) OLR. OLR had lower pre-op Albumin (32±9 Vs 35±8 g/L, p 0.01, Mann-Whitney U), longer hospital stay (10±7 Vs 6±4 days, p 0.00, Mann-Whitney U) and more major liver resections i.e. Resection of 3 or more segments (58% Vs 29% in LLR, p 0.00, Chi2). No difference in IH Incidence in LLR (8%, 19% Vs 10%, 19%) and OLR at 1, 3 years respectively. Similarly, no difference in hernia size (53±37 mm in LLR Vs 50 ± 33 in OLR, p 0.96, Mann-Whitney U) Conclusion No difference in IH incidence or size between LLR and OLR.

Abstract Aim Despite advances in laparoscopic surgery for liver resections, an open approach remains the most frequent approach for complex liver resections for benign and malignant conditions. The aim of this study was to evaluate the clinical outcomes of patients undergoing open liver resections at a single tertiary HPB centre. Method All patients undergoing open liver resections between March 2018-July 2020 were included. Clinical and pathological data was reviewed for all patients and data collected including demographics, indication for surgery, complications, length of hospital stay and 30- and 90-day mortality. Results A total of 51 patients underwent open liver resection with median age of 65 (IQR 60.5-70.5). Indication for surgery included CRC metastasis (45%), HCC (27%), Intrahepatic cholangiocarcinoma (8%), Cholangiocarcinoma (8%), other metastasis (8%). The median hospital stay was 8 days (IQR 6-15). Complications were noted in 17 patients (Clavien-Dindo Classification III (8%) and IV (12 %). 6 patients had post op bile leaks, 4 with grade B and 2 with grade C bile leaks. 8 patients had post hepatectomy liver failure (5 Grade A, 2 Grade B, 3 Grade C). No mortality was noted at 30 and 90-day time-points. Conclusions Our outcomes in terms of morbidity, mortality and hospital length of stay are similar to that in published literature.

Introduction: Routine preoperative biliary drainage prior to a Whipple's procedure is still common in the UK. Recent NICE guidelines (2018) recommend proceeding to unstented surgery in suitable patients. There is level 1 evidence that demonstrates preoperative biliary stenting increases post-operative complications as opposed to early surgery. The study was done to review a single centre experience of early outcomes following stented versus unstented Whipple's procedure. Methods: This is a retrospective review of a prospectively maintained database. 104 patients who underwent a Whipple procedure in 3 years were included. 46 patients underwent preoperative stenting and 58 had Whipple's without stenting. The primary outcomes were rates of pancreatic fistula, bleeding, intra-abdominal collection and wound infections within 90 days post-surgery. The analysis was done using descriptive statistics and non-parametric tests. A two sided significance of p value < 0.05 was considered, with 95% confidence intervals. Results: In Whipple's with preoperative biliary stenting - postoperative pancreatic fistula was seen in 19.56% of patients, bleeding in 10.86%, intra-abdominal collections in 19.56% while wound infection was noted in 26.08%. In the unstented group 27.58% had pancreatic fistula, 24.13% had collections and 5.175% had wound infection. In our study, patients with unstented Whipple's had similar outcomes (albeit not statistically significant) to stented Whipple's, except the rate of wound infection, which was more in stented (p value -0.004). Conclusion: Unstented Whipple's has the potential of shortening the patient pathway and time to definitive treatment. Hence, we advocate increasing adoption of the surgery first approach in suitable patients.Tabled 1Analysis of outcomes - primary and secondary.OutcomesUnstented (n=58)Stented (n=46)p ValuePOPF16 (27.58%)9 (19.56%)0.342Bleeding3 (5.1755%)5 (10.86%)0.461Intra-abdominal collection14 (24.13%)9 (19.56%)0.545Wound infection3 (5.175%)12 (26.08%)0.004Delayed gastric emptying8 (13.8%)6 (13.04%)0.911Re-exploration3 (5.175%)5 (10.8%)0.461Readmissions1 (1.7%)2 (4.34%)0.582Death within 90 days5 (8.6%)3 (6.52%)0.611Death within 30 days2 (3.4%)2 (4.34%)0.612 Open table in a new tab

Background: Heated, humidified co2 insufflation results in decreased post-operative pain & analgesia requirements following laparoscopic surgery. Laparoscopic liver surgery can be technically demanding resulting in above average exposure to dry CO2 insufflation. A warming & hudification system (HumiGard™) was introduced for patients undergoing liver resection at our centre.The aim of this audit was to determine if the introduction of HumiGard™ insufflation have led to reduction in inflammatory response. Methods: Prospectively collected data was retrospectively analysed before and after introduction of HumiGard insufflation for liver surgery. The peak CRP and WBC in the post-op period were compared. Results: From Oct 2013 to Dec 2016 one surgeon carried out 39 laparoscopic liver resections. 22 of these cases were before the introduction of warm insufflation In the pre HumiGard™ era 14 liver resections were minor resections and 8 were major. In the post HumiGard™ era 9 liver resections were major and 8 were minor. The peak CRP and WBC in the post operative period were reduced in the patients undergoing laparoscopic liver resection with HumiGard™ insufflation. (Median WBC 14.6 vs 13.0, Median CRP 49 vs 69). But this did not reach statistical significance. Conclusion: Humidified insufflation may have contributed to the reduction in inflammatory markers in patients undergoing laparoscopic liver surgery. This is an encouraging trend. Further larger studies are needed to evaluate this in laparoscopic liver resection.

To compare outcomes of laparoscopic repair to open repair of umbilical and paraumbilical hernias.

Introduction: Conflicting reports continue to be published on the impact of resection margin (RM) on recurrence in patients undergoing liver resection (LR) for colorectal liver metastases (CRLM). RM of 1cm was the accepted gold standard but recent evidence suggests no difference in survival with RM of up to 1mm with modern chemotherapy. However, a RM≤5mm is associated with increased incidence of local recurrence. This study assesses the impact of RM≤1cm on the incidence of overall and liver recurrence in patients undergoing resection for CRLM. Methods: This is a retrospective study of all patients who underwent resection for CRLM from August 2005 to December 2011with a RM≤1cm. Outcome was any or liver recurrence. Parameters assessed included age, gender, presence of synchronous disease at the time of colorectal resection, chemotherapy use (pre-and post-operative), RM, size of largest metastasis and number of lesions resected. All categorical and continuous variables were analysed using Chi-Square and/or Fisher's Exact Test and Mann-Whitney U test respectively. All factors with p-value≤0.1 was entered into multivariate analysis. Results: 71 (54.1%) of 131 patients who underwent LR between the study period had R1resections. Mean age was 67.5±9.8 years with male:female ratio 50:21. A median of 1 (range1–4) lesion were resected measuring a mean of 38.8 (range4–145mm). Univariate analysis showed increased incidence of recurrence in R1 resections (any recurrence p = 0.018; liver recurrence p = 0.03). There was no difference in the incidence of any or local recurrences between RM1–5mm (p = 0.445) and 5–10mm (p = 0.837). The presence of synchronous disease demonstrated a trend towards liver recurrences only (p = 0.053) but did not reach statistical significance. On multivariate analysis, only R1 affected the incidence of liver recurrence (p = 0.019) but not overall recurrence (p = 0.087). Conclusion: R1 resection is associated with increased recurrence in the liver irrespective of chemotherapy use. There is no difference in recurrence between resection margins1–5mm and 5–10mm.

Introduction The British Society of Gastroenterology (BSG) guidelines state that “Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gall stone aetiology who satisfy the criteria for predicted or actual severe pancreatitis”. The Cochrane review in 2012 suggested that ERCP does not affect morbidity and mortality and some patients with gallstones in the CBD will pass spontaneously. Aim The aim of this study was to assess predictive factors of mortality and the need for ERCP in severe gallstone pancreatitis. Method Data for patients who presented with acute severe biliary pancreatitis between January 2012 and April 2014 was collected. Data collected included predicted severity (Modified Glasgow score), liver function tests, white cell count, USS, ERCP and MRCP reports. Overall 90 day mortality was also recorded. Results 123 patients had predicted severe pancreatitis. On US 21 patients had a dilated CBD and 16 had CBD stone. 51% of patients (n = 63) had MRCP of which 22 patients had CBD stones. 60 patients had ERCP. In 17% (n = 21) no stone was found. 2 patients (3%) developed post ERCP pancreatitis.11% (n = 14)of the patients admitted with predicted severe acute pancreatitis died. On univariate analysis albumin (p = 0.003), alanine transaminase (ALT) (p= <0.05) but not ERCP was significant in predicting mortality. High white cell count demonstrated a trend towards predicting mortality (p = 0.08) but did not reach statistical significance. On multivariate analysis albumin (p = 0.41) and ALT (p = 0.005) retained statistical significance. Conclusion Low serum albumin and ALT predicts mortality in severe GSP but ERCP does not and may precipitate further attacks of pancreatitis. Patients who have severe gallstone pancreatitis without deteriorating LFTs or cholangitis should have an MRCP to confirm stones in the CBD prior to ERCP. Disclosure of interest None Declared.

Introduction The Enhanced Recovery Programme (ERP) has been shown to improve postoperative complications and reduce hospital stay in patients undergoing major HPB surgical oncological resections.1The ERP should allow more patient autonomy in their care and extend beyond the current hospital admission. The benefits of the ERP following hospital discharge are unclear, particularly with regards to adjuvant chemotherapy completion rates. Method A retrospective study was designed looking at the effect of the ERP on adjuvant chemotherapy rates following major pancreatic and liver resections. Patients deemed suitable for curative oncological resection surgery were included in the study. Neo-adjuvant and adjuvant chemotherapy regimens were decided as per the multidisciplinary team decision. Patients in the ERP group who didn’t complete the ERP protocol were analysed in the EPR group on an intention-to-treat basis. Results Between 2005 and 2013, 222 patients (100 liver resections and 122 pancreatic resections; median age 66 years, 1.4:1 male:female ratio) were identified and included in the study, with 142 patients (64.0%) following the ERP protocol. Two-thirds of patients in the ERP group successfully completed the ERP protocol. The ERP did not influence the time to chemotherapy (p = 0.14 pancreas group; p = 0.23 liver group) or successful completion of at least 6 cycles of chemotherapy (0.42 pancreas group; p = 0.06 liver group). Conclusion The ERP has been shown to benefit patients in the immediate postoperative period, with a shorter hospital stay. The results of this study suggest that the benefit of the ERP following hospital discharge is limited and, in particular, does not affect the uptake or successful completion of adjuvant chemotherapy. The effect of the ERP on long-term outcome and cancer-specific survival is, however, still unclear. The ERP following major resection should be further developed to include a stronger community and primary care component to help facilitate care after discharge. Disclosure of interest None Declared. Reference . Jones C, Kelliher L, Dickinson M, et al. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg. 2013July;100(8):1015–1024.

INTRODUCTION:The aim of this study was to evaluate the influence of flurodeoxyglucose positron emission tomography computed tomography (FDG PET-CT), as an adjunct to conventional CT staging, in the detection of extrahepatic disease in patients with potentially resectable colorectal liver metastasis.METHODS:Overall, 133 consecutive patients with colorectal liver metastases staged with CT and PET-CT referred to the East Lancashire regional hepatobiliary multidisciplinary team over a two-year period were included in this study. Abnormal findings on PET-CT were correlated with follow-up imaging and/or histology. All imaging was reviewed by specialist hepatobiliary radiologists for the presence/absence of extrahepatic disease. The influence of the PET-CT findings was categorised for each patient in relation to operability and other significant findings.RESULTS:PET-CT had a major impact on staging of extra hepatic disease in 20% of patients, in comparison with the initial CT. Six per cent of patients were upstaged from operable CT findings to inoperable findings on PET-CT because of the discovery of inoperable occult extrahepatic disease. Five per cent had operable local regional nodal disease detected on PET-CT. A further 3% had premalignant colorectal lesions detected on PET-CT. Six per cent of patients were downstaged from indeterminate or suspected inoperable CT findings to operable findings on PET-CT.CONCLUSIONS:The use of PET-CT in this setting may prevent futile operations, guide the resection of local regional nodal disease and downstage a number of patients thought to have extrahepatic disease on conventional imaging. This study has shown similar results to other recent studies and supports the use of PET-CT as a necessary staging modality in patients with potentially resectable colorectal liver metastases.

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.