Hairmyres Hospital

Abstract Background Excess fat mass and myopenia have been associated with adverse disease outcomes in Crohn’s disease (CD). Despite increasing use of advanced therapies in CD, tools that predict treatment response are lacking. We explored if body composition could predict response to standard-dose adalimumab in active CD. Methods This was a secondary analysis of BIOPIC study, a multicentre randomised controlled trial investigating the effect of partial enteral nutrition in patients with active CD commencing adalimumab therapy. Anthropometry and body composition (bioelectrical impedance analysis, Tanita DC-360P) was measured. Fat mass and fat-free mass were standardised for height (body fat index-BFI and fat-free mass index-FFMI). Patient follow-up was undertaken at 6 and 12 weeks to assess response to adalimumab. Clinical response or remission was assessed by Harvey-Bradshaw Index (HBI) and defined as reduction in HBI ≥ 3 or HBI < 5. Biochemical response (CRP <10) and faecal calprotectin (FCAL) normalisation (<200) were assessed. Therapeutic adalimumab drug levels and anti-drug antibodies (ADAs) were measured. Treatment outcomes and body composition parameters were analysed using logistic regression. Results Seventy-eight participants were included (mean age 40.8 [SD 14.5], 41 (53%) female). Baseline BFI (OR 1.24, CI 1.09-1.41, p = 0.001) and fat mass (OR 1.12, CI 1.05-0.19, p = <0.001) were significant predictors of failure to achieve response or remission to adalimumab by week 12 using a univariate logistic regression model; FFMI was not (OR 1.20, CI 0.98-1.46, p = 0.082). There was no correlation between body composition and baseline disease severity indices or biomarkers. Fat mass and BFI remained predictors of failure to achieve response or remission (OR 1.16, CI 1.07-1.26, p = 0.001, OR 1.27, CI 1.03-1.47, p = 0.002 respectively) after adjusting for disease duration, disease severity (HBI), sex and corticosteroid use. Fat mass also predicted failure to normalise CRP (OR 1.07, CI 1.01 – 1.13, p = 0.025) but body composition parameters could not predict normalisation of FCAL. Sixty-six participants had adalimumab drug levels and ADAs measured. Fat mass (%) was negatively correlated with adalimumab drug levels (r = -0.409, p < 0.001), positively correlated with ADAs (r = 0.300, p = 0.014) and predicted formation of ADAs to adalimumab (OR 1.07, CI 1.00-1.15, p = 0.043). Conclusion Adiposity predicts risk of treatment failure with standard dose adalimumab. This may be related to suboptimal therapeutic drug levels and increased risk of immunogenicity. Intensive monitoring of therapeutic drug levels and adjustment of adalimumab dose according to adiposity may be considered. Conflict of interest: Dr. Fattah, Sharif: No conflict of interest White, Bernadette: No conflict of interest Campbell, Iona: No conflict of interest Fandinga, Catarina: No conflict of interest Clowe, Jennifer: No conflict of interest Brownson, Emily: No conflict of interest Ho, Gwo-Tzer: No conflict of interest Robertson, Elaine: No conflict of interest Mowat, Craig: No conflict of interest Gaya, Daniel: No conflict of interest Kefayat, Amirhosein: No conflict of interest Din, Shahida: No conflict of interest Seenan, John Paul: No conflict of interest Macdonald, Jonathan: No conflict of interest Gerasimidis, Konstantinos: Grant: Nestle Health Science, Nutricia-Danone, Mylan Personal Fees: Abbott, Baxter, Nestle Health Science, Nutricia-Danone, Servier, Janssen

Abstract Aim Higher surgeon case volumes are often associated with improved patient outcomes, particularly in complex or high-risk procedures. While laparoscopic cholecystectomy (LC) is a commonly performed operation, variability in outcomes persists. This study aimed to evaluate whether individual surgeon case volume influences clinical outcomes in LC. Method This multicentre retrospective cohort study included consecutive adult patients who underwent elective or emergency LC across three hospitals within a single health board between August 2023 and July 2024. Surgeons were categorised as high-volume (>50 cases/year) or low volume (≤50 cases/year) based on their annual operative caseload. Clinical and perioperative outcomes were compared between the two groups. Results Of the 564 patients, 178 (31.6%) were performed by high-volume surgeons and 386 (68.4%) by low-volume surgeons.High-volume surgeonn=178Low-volume surgeons n=386P valueMedian Age55 years (IQR 40-63)53 years (IQR 38-63)0.355Female114 (64%)291 (75.4%)0.005Emergency Cases79 (44.4%)131 (33.9%)0.017Intra-operative cholangiogram117 (65.7%)95 (24.6%)<0.001Bile duct exploration51 (28.7%)21 (5.4%)<0.001Subtotal cholecystectomy9 (5.1%)44 (11.4%)0.016Median post-operative length of stay1 day (IQR 0-2)1 day (IQR 0-3)0.042Readmission within 30 days7 (3.9%)31 (8%)0.071Complications:Clavien-Dindo 1-211 (6.2%)26 (6.7%)0.804Clavien-Dindo 3-45 (2.8%)29 (7.5%)0.029 Conclusions Higher surgical volumes are associated with better outcomes in LC, despite increased case complexity. These findings support subspecialisation and suggest that gallstone surgery should be concentrated among dedicated surgeons to optimise patient safety, efficiency, and overall surgical quality.

Abstract Aim Early-onset oesophago-gastric (OG) cancer, defined as malignancy of the oesophagus or stomach diagnosed before the age of 50 is increasingly recognised as a distinct clinical entity. Global data suggest a rising incidence, with younger patients often presenting with different biological behaviour and diagnostic challenges. This study aimed to assess the prevalence of early-onset OG cancer within our population and to describe its clinicopathological features. Method A retrospective cohort study was performed across a single health board, including all patients diagnosed with oesophageal or gastric cancer between January 2017 and December 2022. Electronic records were reviewed to collect demographic, clinical, pathological, and treatment data. Patients diagnosed before age 50 were classified as early-onset OG cancer and included in the analysis. Variables assessed included presenting symptoms, tumour site, histological subtype, disease stage, and treatment intent (curative or palliative). Results A total of 784 patients were diagnosed with OG cancer during the study period, of whom 533 (68%) were male. Early-onset OG cancer accounted for 38 (4.8%) cases. Among these, 23 (60.5%) were oesophageal cancers and 29 (76.3%) were adenocarcinomas. The median age at diagnosis in this group was 42 years (IQR 38–47). Regarding treatment intent, 20 patients (52.6%) were referred for palliative chemotherapy, while 11 (28.9%) underwent treatment with curative intent. Conclusions Although infrequent, early-onset OG cancer represents a clinically relevant subgroup. Increased awareness is vital, as younger patients may present with advanced disease. Further research is needed to inform risk stratification and optimise management.

Abstract Aim Laparoscopic cholecystectomy (LC) is recognized for its diverse complexity between cases, which profoundly influences perioperative progression and patient outcomes. It is notoriously difficult to accurately predict surgical complexity pre-operatively. We hypothesise that the difficulty of cholecystectomy has increased in recent years. Method A retrospective review was conducted over a 34-month period, including all consecutive laparoscopic cholecystectomies performed by two consultant biliary surgeons. Operative difficulty was prospectively graded using the Nassar Cholecystectomy Scale. Results were compared to published data from the CholeS study to assess changes in case complexity over time. Results 319 laparoscopic patients were identified. The table below compares our results with Choles study.CholeS Study(N=8,755)Our Study(N=319)P valueEmergency cases1,391 (15.9%)98 (31.0%)<0.001Nassar Cholecystectomy Scale:13,524 (40.6%)34 (10.7%)<0.00122,608 (30.0%)103 (32.3%)0.39731,769 (20.4%)69 (21.6%)0.5344/5779 (9%)113 (35.4%)<0.001Intraopertaive cholangiogram1,052 (12%)230 (72.1%)<0.001Bile duct exploration256 (2.9%)92 (28.8%)<0.00130-day readmission618 (7.1%)15 (4.7%)0.105Complications937 (10.7%)20 (6.3%)0.011 Conclusions Our findings demonstrate a clear increase in both the proportion of emergency laparoscopic cholecystectomies and operative difficulty, as reflected by higher Nassar grades, compared to the CholeS study. This trend likely reflects broader systemic pressures, including delayed access to theatre, evolving patient comorbidities, and resource constraints. Prioritising index admission cholecystectomy is essential to reduce readmissions and mitigate progression to more complex, higher-risk procedures.

Abstract Aim Readmissions within 30 days of cholecystectomy pose a significant healthcare burden, with Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) setting the benchmark at <10%. This study examines the incidence, causes, and impact of 30-day readmissions following cholecystectomy. Methods This multicentre retrospective study included all adult patients undergoing elective and emergency laparoscopic cholecystectomy at three hospitals in single health board between August 2023 and July 2024. Data collected included demographics, operative details, and postoperative outcomes, including readmission rates and causes. Results 564 patients were identified, median age was 53 years and 404 (71.6%) were female. 210 (37.2%) were emergency cases. 212 (37.6%) patients also had intra-operative cholangiogram (IOC) and 72 (12.8%) patients also had laparoscopic bile duct exploration. 35 (6.2%) patients had readmission within 30-day of surgery. Median total hospital stay after readmission was 3 days (IQR 2-6). Causes of readmission included postoperative abdominal pain (11 patients), bile leak (5 patients), CBD stones (5 patients), and intra-abdominal collection (2 patients). Rare causes, each affecting one patient, included CBD stricture, AKI, C. difficile infection, cholangitis, constipation, DVT, fall, ileus, pancreatic insufficiency, stroke, port site infection, and transverse colon colitis. Conclusion Readmission rates are within the accepted range but can be improved. Common causes include postoperative pain, bile leaks, and CBD stones. Liberal use of IOC, meticulous surgical technique, effective analgesia, and discharge information leaflets may help reduce these complications and readmissions.

Abstract Aim Operation notes serve as the standard documentation of intraoperative findings. The Royal College of Surgeons of England (RCS) and NHS England introduced the Getting It Right First Time (GIRFT) program, outlining 32 essential components for operation notes. This study evaluates the quality of laparoscopic cholecystectomy operation notes before and after implementing GIRFT recommendations. Methods A retrospective analysis of laparoscopic cholecystectomy operation notes from two biliary surgeons over a two-year period was conducted. Following the first audit cycle, GIRFT recommendations were implemented. Operation notes were then reassessed and compared before and after adopting these recommendations. Results A total of 245 operation notes were included. There were 132 operation notes in the first cycle and 113 in second cycle. All operation notes included 19 out of 32 recommended points, such as operation indication, consent, date/time of operation, surgical checklist, skin preparation and drugs administered. Further details are specified in the table below. Cycle 1 (n=132)Cycle 2 (n=113)Median GIRFT score27 (IQR 26-29)30 (IQR 29-32)All (32) GIRFT points included037 (32.7%)Laparoscopic pressure settings095 (84.1%)Laparoscope under direct vision2 (1.5%)77 (68.1%)Reverse Trendelenburg Position4 (3.0%)79 (69.9%)Intraoperative Pictures94 (71.2%)88 (77.9%) Discussion This study demonstrates improved quality of operation notes following the implementation of GIRFT guidelines. Adopting these standards should be encouraged and integrated into surgical training to enhance consistency and patient care. Additionally, incorporating instant digital upload of intraoperative photos could further improve documentation and prevent data loss.

Abstract Aim Patients with a high Body Mass Index (BMI≥35) undergoing benign biliary surgery are often perceived to be at greater risk for postoperative complications and prolonged post-operative length of stay. This study aims to compare postoperative complication rates between obese and non-obese patients. Methods A retrospective analysis of all consecutive laparoscopic cholecystectomies performed by two biliary surgeons over two years. Patients were divided into two groups based on their BMI (group-1 BMI≤35.0, group-2 BMI>35.0) and the outcomes compared. Results 245 patients were identified, 193 patient in group 1 and 52 were in group 2. Median BMI in group-1 was 29 and 39 in group-2. Table below compares the data in both groups. Group 1 (BMI≤35.0) n=193Group 2 (BMI>35.0) n=52P valueMedian Age56 years (IQR 44-67)45 years (IQR 37-58)0.005Female117 (60.6%)40 (46.9%)0.030Emergency Cases80 (41.5%)16 (30.8%)0.161Nassar Cholecystectomy Grade 4 & 573 (37.8%)16 (30.8%)0.348Intra-operative cholangiogram89 (46.1%)22 (42.3%)0.625Bile duct exploration59 (30.6%)16 (30.7%)0.978Median post-operative length of stay1 day (IQR 0-2)1 (day IQR 0-2)0.349Readmission within 30 days11 (5.7%)2 (3.8%)0.597Complications:Clavien-Dindo 1-210 (5.2%)1 (1.9%)0.314Clavien-Dindo 3-46 (3.1%)00.198 Discussion This study shows that postoperative outcomes in obese patients undergoing benign biliary surgery are comparable to those in non-obese patients. Surgeons should be encouraged to operate on obese patients to prevent complications associated with gallstone disease.

Abstract Aim Laparoscopic cholecystectomy is one of the most commonly performed procedure by general surgeons. Routine use of Group and Save (G&S) is widely practiced despite limited supporting evidence. This study aimed to evaluate the necessity of routine G&S by assessing perioperative blood transfusion rates. Methods This was a multicentre retrospective observational study of all consecutive adult patients undergoing elective and emergency cholecystectomy at three hospitals between August 2023 and July 2024. Data collected included patient demographics, operative details, Group and Save (G&S), cross-matching, and perioperative blood transfusion requirements. The laboratory cost of analysing a G&S sample is estimated to be £36 per patient and £124 for each unit for cross match. Results 564 patients were identified, median age was 53 years and 404 (71.6%) were female. 212 (37.6%) also had intra-operative cholangiogram and 72 (12.8%) had common bile duct exploration. 561 (99.5%) patients had pre-operative G&S. 31 (5.5%) also had cross match, with a total of 54 units cross matched. Two (0.4%) patients required blood transfusion within 30 days of surgery, both after 7 days of surgery. The cost estimated to be £20,304 for G&S and £6,696 for cross match - a total cost of £27,000. Conclusions Perioperative blood transfusion is exceedingly rare in patients undergoing cholecystectomy. Routine G&S testing imposes significant costs and can lead to unnecessary delays if not performed promptly. Our findings suggest that a routine G&S policy is unnecessary, and we recommend adopting a 'highly selective' G&S approach.

Abstract Aim Laparoscopic cholecystectomy is among the most commonly performed general surgical procedures but carries a risk of potentially serious postoperative complications. Obtaining informed consent is crucial to ensure patients understand these risks and to minimize the likelihood of costly litigation. This study compares variations in consenting practices between biliary and non-biliary surgeon performing laparoscopic cholecystectomy, with a focus on documenting significant biliary risks. Methods This multicentre retrospective study included consecutive adult patients who underwent elective and emergency cholecystectomy at three hospitals between August 2023 and July 2024. The health board comprises over 30 general surgeons, including two biliary specialists managing complex cases. Consent forms were analysed and compared between biliary and non-biliary surgeons. Results 564 patients were identified, median age was 53 years and 404 (71.6%) were female. 210 (37.2%) were emergency cases. 125 (22.2%) cholecystectomies were performed by biliary surgeon and 439 (77.8%) by non-biliary surgeon. Bile leak and bile duct injury (including rate of injury) was documented more often by biliary surgeon as compared to non-biliary surgeon (95.2% vs 82.5%, p<0.001 and 87.2% vs 21.2%, p<0.001, respectively). Post-cholecystectomy syndrome and conversation to open surgery was also documented more often by biliary surgeon as compared to non-biliary surgeon (91.2% vs 52.8%, p<0.001 and 99.2% vs 92.7%, p0.006; respectively) Conclusions The quality of consent for laparoscopic cholecystectomy was higher when obtained by biliary surgeons. This study underscores the importance of thorough and high-quality consent. Implementing procedure-specific consent forms alongside patient information leaflets can significantly enhance the consent process.