Abstract Background Deprivation is a complex, multifaceted concept, not synonymous with poverty, but with the potential to widen health inequalities. This study aimed to explore demographic disparities in patients undergoing UGI cancer surgery in a UK regional cancer network during the COVID-19 pandemic. Method Consecutive 881 patients were studied prospectively (median age 67 (24 - 89) yr., 703 m, 178 f; 518 oesophageal, 363 gastric; 837 Adeno-, 44 SCC) over 13 years. The COVID-19 pandemic was defined as the 24-month period from February 1, 2020 to January 31, 2022, during which 118 patients were treated. The demographic profile of the pandemic cohort was compared with that of the 763 patients treated outside this period incorporating a propensity score analysis. Primary outcomes were operative morbidity, mortality, and one-year survival. Wales’ Index of Multiple Deprivation was used to assess deprivation disparity. Results A 24% reduction in the number of cancer operations was observed during the first pandemic year. No difference was observed in age, gender, histology, tumour site, ASA grade, or oncological treatment. During COVID-19 the proportion of patients from the two most deprived quartiles receiving potentially curative surgery fell from 53.2% to 40.7% (p=0.012). No difference was observed in severe morbidity (Clavien-Dindo >3, 22.2% vs. 19.8%, p=0.897), 30-day mortality (2.5% vs. 2.4%, p=0.886), or one-year survival (82.4% vs. 78.8%, p=0.374). Conclusion UGI cancer surgery safely continued during COVID-19, but patients from areas of high deprivation were over 20% less likely to access curative surgical treatment compared with before and after COVID-19. This emphasises the need for bespoke strategies to mitigate the disproportionate impact of any future pandemic on patients living in deprived geographical areas.

Abstract Aims Oesophageal Cancer (OC) treatment levies substantial financial burden on health services with potentially curative surgery with or without neoadjuvant offered to patients with locoregional disease. This study aimed to examine treatment costs related to Quality Adjusted Life-Years (QALYs) gained in patients that have potentially curative treatment (oesophagectomy) and those receiving best supportive care (BSC). Methods Consecutive 365 patients undergoing potentially curative treatment (median age 64.5 years, 308 male, 57 female, 331 adeno ca, 32 squamous cell ca, 2 high grade dysplasia, 263 neoadjuvant therapy) were studied. The cost of one-year’s treatment from referral was calculated based on current management standards within a regional cancer network and primary outcome was overall survival. Results QALY-adjusted survival for stage I was 48 months, stage II 30.6 months, stage III 23.0 months, and stage IV 13.0 months, with cost per QALY of £6038, £13412, £14606, and £20002 respectively. QALY-adjusted survival for patients receiving BSC was 2.24 months, with a cost per QALY of £60225. This gives an Incremental Cost-Effectiveness Ratio (ICER) per QALY for stages I to IV of £3385, £9714, £8740 and £17763 respectively. Conclusion Cost per QALY of potentially curative OC treatment for each stage was below national thresholds of readiness to pay per QALY, while BSC likely exceeds this. Regarding ICER-defined cost effectiveness, treatment of stage I was five-fold cheaper than stage IV OC, supporting early diagnosis as being most cost-effective.

Abstract Introduction Socio-Economic Deprivation has long been associated with many gastrointestinal diseases yet its influence on OesophagoGastroDuodenoscopy (OGD) findings has not been evaluated. The aim of this study was to investigate the influence of deprivation on outcomes of OGD irrespective of referral reason. Method Two-thousand consecutive patients presenting to four Health Boards in Wales (June 2019-) were studied retrospectively with deprivation scores calculated using the Wales Indices of Multiple Deprivation (WIMD). Patients were subclassified into Quintiles for analysis (Q1 most, Q5 least Deprived). Results Inhabitants of the most deprived areas were more likely to be diagnosed with Peptic Ulcer (Q1 7.9%, Q5 4.7%; OR 0.498, p=0.018), Severe Oesophagitis (LA4, Q1 2.7% v Q5 0%, OR 0.089, p=0.002), Helicobacter Pylori infection (Q1 5.4%, Q5 1.7%; OR 0.284, p=0.002), but less likely to be diagnosed with Barrett’s Oesophagus (Q1 6.3% v Q5 12.3%, OR 2.146, p=0.004) than those from least deprived areas. New cancer diagnoses numbered 53 and were proportionately higher after Urgent Suspected Cancer (USC) referral (n=35, 4.6%) with three diagnosed after routine OGD (0.6%, p<0.001). Deprivation was associated more advanced radiological perceived Stage III Cancer (Q1 16.1% v Q2 55.6% v Q5 5.6%, OR 0.007, p=0.005). Conclusion Deprivation was associated with two-fold more peptic ulcer disease, three-fold more Helicobacter Pylori infection, and 12-fold more severe oesophagitis, which correlated with up to 10-fold more advanced cancer stage at diagnosis.

Abstract Background Upper Gastro Intestinal (UGI) cancer surgery carries considerable risk and cost in terms of human and financial resource. Reported complication rates after oesophagectomy and gastrectomy are 65% and 42% respectively and can range from relatively minor morbidity to major life-threatening events, all with the potential to increase Length of Stay (LoS) and cost which can be graded by the Clavien-Dindo (CD) system. This study aimed to study the impact of complications on LoS and quantify the associated economic costs. Methods Consecutive 754 patients with UGI cancer (420 oesophageal, 334 gastric), undergoing potentially curative treatment (median age 67 yr., 590 m, 164 f, 684 Adeno Ca, 36 SCC, 205 Ivor-Lewis oesophagectomy, 146 Trans Hiatal oesophagectomy, 142 total gastrectomy, 134 subtotal gastrectomy, 97 open and close, 11 Three-stage oesophagectomy, 10 salvage resections, 8 oesophagogastrectomy) were studied. The cost of each night’s stay was limited to direct costs, including ward and medical staff expenditure. Results Median LoS was 13 (IQR-7) days. The number of patients related to CD score were; Zero-326, I-41, II-224, IIIa-44, IIIb-28, IVa-36, IVb-4 and V-16, with median LoS of 11, 14, 14, 23, 25, 32, 44 and 9 days respectively. The added LoS for each complication cohort was 3 days for CD I and II, then 12, 14, 21, and 33 days for CD IIIa, IIIb, IVa and IVb respectively. Average added cost for each grade of complication per patient was £844.44 for CD I and II, £3,377.76 for IIIa, £8,519.40 for IIIb, £14,927.70 for IVa and £36,047.85 for IVb. Conclusions Overall hospital and CC LoS increased related to complication grade, other than CD V, with an average ward cost per additional day of £281.48 and CC cost of £1426.15. Average cost of an uncomplicated oesophagectomy or gastrectomy was estimated to be £16,544. As well as the adverse impact on patients’ recovery and well-being, complications have a large fiscal impact on healthcare systems and in many cases can dwarf the first treatment cost. These findings illustrate a strong clinical and business case for investment in effective strategies to boost complication free surgery including pre-habilitation.

Abstract Background It has been widely reported that the COVID-19 pandemic has had a detrimental impact on waiting lists for elective surgery in the NHS. Delays in laparoscopic cholecystectomy (LC) are likely to prolong suffering for symptomatic patients and risk increasing complications for patients which may then require emergency care and intervention. In this study we aim to quantify the impact of the COVID-19 pandemic on elective waiting lists and to assess what implications this might have on patient care and outcomes. Methods Electronic health records were retrospectively interrogated for patients undergoing LC in both March 2019 (prior to the COVID-19 pandemic) and March 2021. The following data was captured: age, gender, elective vs emergency operation, laparoscopic vs open, total vs subtotal cholecystectomy, use of drains, length of stay/daycase rates, the number of emergency presentations prior to operation and the number of days between being listed for surgery and their operation. The results were analysed using SPSS Statistics (IBM, New York). Results 111 patients were included in the study (25 male and 86 female). Of these, 60 had their LC in 2019, and 51 in 2021. The age and gender distribution of the patients in both time periods were similar. The median number of days on the waiting list was significantly higher (P < 0.001) for patients in 2021 at 379.5 days, compared with 153 days in 2019. There was a significant increase in the number of emergency presentations prior to LC in 2021 (P = 0.025) with an average of 0.7 presentations per patient compared with 0.45 in 2019. Additionally, there was a significant increase in the number of emergency LC performed in 2021 (P = 0.002), with 15 performed compared with 4 in 2019, representing 29.4% and 6.7% of all LC respectively. There was no significant change in rates of conversion to open, drains or subtotal cholecystectomy. There was no significant difference in daycase rates for elective patients in either period (55% vs 58%). Conclusions Whilst there has been no change in the operative outcomes for patients undergoing LC, there has been a stark increase in the length of time patients are on a waiting list prior to undergoing elective LC. This has resulted in a significant increase in the number of emergency presentations and the number of emergency LC performed. This study demonstrates the wider impact of increasing waiting list times beyond the prolonged suffering of symptomatic patients. A significant reduction in waiting list times would be beneficial to both patients and healthcare providers, with the aim of reducing the number of emergency presentations. A reduction in these would have a positive impact on acute services and on the associated cost implications.