Lewisham and Greenwich NHS Trust

Objective: Aquablation is FDA and NICE approved for treating benign prostatic hyperplasia (BPH). In the UK, increasing surgical elective waiting lists have created the need for HIT list models. We present a tertiary centre experience using Aquablation within a HIT list framework and compare it to standard operating protocol (SOP). Methods: A prospective cohort study was performed with 60 patients awaiting bladder outlet surgery. Ten patients were operated using HIT protocol and compared to 50 patients under SOP. We assessed differences in perioperative outcomes and complications, including postoperative follow-up. Results: There was a significant decrease in IPSS from 24.92 to 5.93 ( p = 0.001) and 93% ejaculation preservation. A significant difference in postoperative Hb decrease was observed, with HIT = 5.3 g/L vs SOP = 12.3 g/L ( p < 0.05). No blood transfusions were needed. Operative times were similar, with the HIT group having a median of 56 minutes and the SOP group 59 minutes. Conclusion: Our analysis demonstrates that the introduction of Aquablation in a tertiary centre is feasible for managing moderately enlarged prostate glands (80–150 ml). The implementation of a dual operating theatre HIT list using a single Aquabeam robotic system appears to be a viable strategy for increasing surgical capacity. While initial results suggest comparable perioperative outcomes to standard operating protocol, further studies with larger cohorts are required to assess the long-term safety and broader applicability of this approach. Level of evidence: 3

Abstract Background It is uncertain if sessile serrated lesions (SSLs) in patients with inflammatory bowel disease (IBD) represent coincidental sporadic lesions or a distinct biological entity. Molecular studies suggest SSLs in IBD are more frequently KRAS mutated, contrasting with the BRAF driven pathway typical of sporadic SSLs.¹,² More recent data supports a distinct clinicopathologic and molecular profile,3 the understanding of which is critical for optimising surveillance strategies. Methods Colonic serrated lesions from St. Mark’s Hospital pathology database (2014–2022) were reviewed and classified as SSL or dysplastic SSL (SSL-D) and stratified by disease background: IBD, serrated polyposis syndrome (SPS) or sporadic. Cases with overlapping conditions or indeterminate features were excluded. Lesion size, location, patient demographics and IBD subtype and extent were compared. Ethical approval was obtained for this study. Results IBD group: 224 SSLs were identified (200 SSL, 24 SSL-D; dysplasia rate 10.7%). 132 out of 157 patients had ulcerative colitis. No significant differences were seen in lesion location, size or IBD related factors between SSL and SSL-D (Table 1). Median cumulative inflammatory burden for SSL-D was 3.58. SSL-Ds did not show a significant right-sided predominance. SSL-Ds were more frequent in older patients (median 69 vs 60 yrs, p = 0.006). Sporadic group: 5304 SSLs (5030 SSL, 274 SSL-D; dysplasia rate 5.2%) were identified. SSL-Ds were predominantly right-sided and more frequent in older patients (median 68 vs 61 yrs; p < 0.001). SPS group: 4554 SSLs (3662 SSL, 82 SSL-D; dysplasia rate 2.2%) were identified. SSL-Ds were also mainly right-sided and more frequent in older patients (median 64 vs 41 yrs; p < 0.001). The proportion of low to high grade dysplasia was similar across groups (p = 0.32), but dysplasia rates were significantly higher in IBD (p < 0.000001). SSL-Ds occured throughout the IBD colon, lacking the right-sided predominance seen in sporadic or SPS cases (IBD p = 0.3; Sporadic p = <0.001; SPS p = 0.007). Demographically, groups were similar with no significant age difference (p = 0.058). Conclusion SSLs in IBD show a significantly higher dysplasia rate than those in SPS or sporadic cases, despite similar demographic and morphologic features. SSL-Ds in IBD were more likely to be found throughout the colon compared with the typical right sided dominance seen in SPS and sporadic cases. Traditional risk factors for advanced neoplasia, including disease duration and extent, did not distinguish dysplastic from non-dysplastic SSLs in IBD, although small numbers of SSL-D may underestimate significant findings. Further clinical and molecular investigation is needed to clarify the unexpectedly high dysplasia rate in IBD associated SSLs.

Background Cauda equina syndrome (CES) is a rare but serious condition caused by compression of the lower spinal cord. Early recognition and prompt intervention are essential to prevent irreversible neurological damage. Delays in diagnosis or treatment can lead to permanent disability and may result in significant medicolegal consequences. Aim The aim of this quality improvement project (QIP) was to identify areas for improvement in the diagnosis of CES and update local guidelines in line with the Get It Right First Time (GIRFT) recommendations. Methods and Results This retrospective study, conducted according to GIRFT guidelines, examined patients admitted to the District General Hospital Emergency Department with suspected CES. A total of 37 patients—8 males (21.6%) and 29 females (78.4%)—were assessed over a six-month period from January to June 2023. Patients without CES listed as a differential diagnosis were excluded. Data collected included documentation of neurological examinations, post-void residual scans, perianal sensation assessments, MRI request and completion times, and length of stay. Findings were presented at the Trauma and Orthopedics mortality and morbidity meeting. Overall, 89.19% of MRI scans were completed within 24 hours of request, while 10.81% exceeded this timeframe. Notably, 57% of patients did not undergo a comprehensive neurological examination on admission. Following these findings, a CES proforma was introduced to standardize the assessment process. In the subsequent cycle, documentation improved significantly, demonstrating the effectiveness of the intervention. Conclusion This QIP highlighted key areas requiring improvement, particularly the inconsistent completion of neurological examinations and delays in MRI access for suspected CES cases. Collaboration with the Emergency Department and radiology services led to the implementation of a CES assessment proforma, ensuring timely and consistent evaluation of patients. This structured approach supports earlier diagnosis, aligns with GIRFT standards, and enhances the quality and safety of CES management within our hospital.

<h3>Background</h3> Clinical outcomes for NTM-PD are often poor. The NTM Network UK Standards of Care were launched in 2024 to support consistent, high-quality practice including pharmacological and non-pharmacological treatment. We aimed to document NTM-PD management prior to this to identify opportunities to improve care. <h3>Methods</h3> Centres were invited via the NTM Network UK to complete an online retrospective survey. At each site, anonymised clinical data were recorded from three consecutive adults (≥18) newly diagnosed with NTM-PD from 1 January 2022. <h3>Results</h3> 48 centres participated (Northern England, n=12; Southern England, n=12; London, n=9; Wales, n=7; Midlands, n=6; Scotland, n=2) They reported having the following resources: physiotherapy for airway clearance (n=42/48, 88%), dietitian and pulmonary rehabilitation (each n=32, 67%), specialist nurse (n=30, 63%), and health psychology (n=9, 19%). Respondents contributed data on 137 patients. 72 (53%) were female and 115 (84%) identified as White-British. 45 (34%) were aged 61–70. 62 (45%) had COPD and 55 (40%) bronchiectasis. Common radiological findings were nodular-bronchiectatic change (n=62, 45%), fibro-cavitary disease (n=40, 29%), and emphysema (n=39, 28%). <i>Mycobacterium avium complex</i> (MAC) was identified in 106 (77%), <i>M. kansasii</i>(n=14, 10%) and <i>M. abscessus</i> (n=9, 7%). Eighty-one (59%) patients were discussed in an MDT. Treatment plans included involvement of specialist nurses (n=91, 66%), physiotherapists (n=52, 38%), dietitians (n=34, 25%), and pulmonary rehabilitation (n=16, 12%). Forty-two (31%) were advised on airway clearance using Active Cycle Breathing, 25 (18%) Positive Expiratory Pressure devices, 17 (12%) mucoactive drugs, and 12 (9%) hypertonic saline. Written resources were provided to 39 (28%) patients, 22 (16%) were directed to patient-focused websites, and 13 (10%) signposted to peer-support networks. During a median follow-up from diagnosis of 21 (IQR 14–29) months, 124 (91%) started antibiotics for NTM-PD. Forty-five (33%) remain on follow-up and using antibiotics, 53 (39%) are not on antibiotics, 26 (19%) were discharged, and 12 (9%) died. <h3>Conclusion</h3> This UK-wide assessment of NTM-PD management reveals significant variation in available services and care provided. Most patients started specific antimicrobials, though non-medical health care support and patient information provision were limited. We have identified important areas for re-audit against the 2024 Standards.

Abstract Aims The role of neoadjuvant chemotherapy in treating Borderline Resectable Pancreatic Cancer (BRPC) has been defined and supported by trials. This study aims to assess the outcomes of patients with BRPC who undergo neoadjuvant chemotherapy and those who undergo upfront surgery. Methods Patients with BRPC from January 2020 – January 2023 were retrospectively identified from regional multidisciplinary team records. Patients unfit for surgery or who declined surgery were excluded. Data were extracted from electronic patient records. Key outcomes included progression of disease, progression to surgery, resectability, survival, and postoperative complications. Results 21 patients were included, 12 male and 9 female. 20 patients were planned for surgery after neoadjuvant chemotherapy. 4 patients (20.0%) did not progress to start treatment, 3 (15.0%) did not progress to surgery, and 4 resections were abandoned after exploratory laparotomies (20.0%). 9 patients (45.0%) progressed to tumour resection; 4 with R0 margins and 5 with R1 margins. The progression-free survival ranged from 6 months to 50 months (uncensored), excluding 1 postoperative death within 30 days. The two-year overall survival rate was 50%. 1 patient had upfront surgery and a progression-free survival of 12 months with overall survival of 18 months. Conclusion Due to the limited sample size, comparative analysis between subgroups could not be performed, and overall survival data were not censored. Outcomes in patients who underwent neoadjuvant Chemotherapy are aligned with research trials. This study also highlighted potential delays within the treatment pathway, identifying the need for a standardised, centralised protocol to optimise patient management.

Abstract Background/Aims Eosinophilic fasciitis (EF) is a rare disorder characterised by inflammation in the fascia that results in non-pitting oedema, followed by collagenous thickening. However, the pathogenesis is poorly understood and the condition is heterogeneous in both its symptoms and severity. Despite the name of the condition, it is important to understand that peripheral eosinophilia and the presence of eosinophils in the skin biopsy are not essential in making a diagnosis of EF. Methods A 58-year-old black woman, with hypertension, diabetes, alopecia and dilated cardiomyopathy, presented with a six-month history of bilateral progressive swelling in her forearms and calves, with skin tightening and significant weight loss, but no history of Raynaud’s. On examination, she had tender, symmetrical, thickened skin in the forearms and calves, which was shiny and indurated, with elbow and knee contractures to 120 degrees and a positive groove sign. She had no sclerodactyly, nailfold changes, calcinosis, telangiectasias or synovitis. She had preserved power throughout all limbs with normal sensation. Cardiovascular and respiratory examinations were unremarkable. Results Bloods showed ESR 34mm/h and CRP 27mg/L, with negative rheumatoid factor, anti-CCP antibodies, ANA, myositis antibody panel and ANCA. IgG was elevated (25.6g/L), with no paraprotein. She had mild leucocytosis (11.4x109/L) with neutrophilia (8.2x109/L), but normal eosinophils (0.3x109/L). CT chest/abdomen/pelvis showed no malignancy but small volume right axillary and pelvic lymph nodes. MRI forearm showed intermuscular fascial thickening and oedema, with subcutaneous oedema consistent with EF. Deep skin biopsy showed thickening of the fascia with lymphoplasmacytic inflammatory infiltrate but no eosinophils, but in keeping with EF. She was treated with prednisolone 40mg once daily, but lack of progress led to escalation of therapy with intravenous methylprednisolone 500mg for three days, followed by prednisolone 0.5mg/kg and a slow wean. Methotrexate 20mg once weekly was added, alongside hydroxychloroquine 200mg once daily. Her inflammatory markers improved with treatment (ESR 28mm/h, CRP 5mg/L) yet there was no significant change in her contractures, swelling and pain. Conclusion EF is a rare disease and it is important to have a high index of suspicion in a patient who presents with scleroderma-like skin with no history of Raynaud’s. A dual approach of MRI and deep skin biopsy helps support the diagnosis, especially in the absence of significant peripheral eosinophilia. Peripheral eosinophilia and histopathological infiltration of eosinophils in the fascia are effective, but not essential, for a diagnosis of EF. Furthermore, there is no standardised treatment pathway for EF, but whilst steroids are often effective at inducing remission, in this case steroids had a limited impact. It raises the question of whether this is secondary to the lack of peripheral eosinophilia and eosinophils on the biopsy. This may represent a subset of EF patients with poor response to standard therapy. Disclosure D. Srikantharajah: None. J. Kimpton: None. Y. Man: None.