N Stern

Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics

Objective To determine whether variation in gastroscopy rates in English general practice populations is associated with inequality in oesophagogastric (OG) cancer outcome. Design Retrospective observational study of the Hospital Episode Statistics (HES) dataset for England (2006–2008) linked to death registration. Methods were validated using independent local and national data. General practices with new cases of OG cancer were included. Practices were grouped into tertiles according to standardised elective gastroscopy rate per capita (low, medium or high). Outcome measures for cancer cases were: emergency admission during diagnostic pathway, major surgical resection and mortality at 1 year. Covariates were: age group, gender, comorbidity, general practice average deprivation and patient deprivation. Results 22 488 incident cases of OG cancer from 6513 general practices were identified. Patients registered with the low tertile group of practices had the lowest rate of major surgery, highest rate of emergency admission and highest mortality. The inequality was widest for the most socioeconomically deprived cases. After adjustment for covariates in logistic regression, the gastroscopy rate (low, medium or high) at the patients general practice was an independent predictor of emergency admission, major surgery and mortality. Conclusions There is wide variation in the rate of gastroscopy among general practice populations in England. On average, OG cancer patients belonging to practices with the lowest rates of gastroscopy are at greater risk of poor outcome. These findings suggest that initiatives or current guidelines aimed at limiting the use of gastroscopy may adversely affect cancer outcomes.

Metal stents: a bridge to surgery in hilar cholangiocarcinoma

BACKGROUND Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma. METHODS A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded. RESULTS Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively. CONCLUSIONS Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.

Portal vein cannulation: An uncommon complication of endoscopic retrograde cholangiopancreatography

Portal vein cannulation is a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). It has been reported that it usually occurs after endoscopic sphincterotomy, whereas in cases without prior sphincterotomy, the presence of portobiliary fistulas has been shown. Here, we present a case in which cannulation of the portal vein occurred despite careful wire-guided cannulation and the absence of sphincterotomy. Although fatal cases of cerebral and pulmonary air and/or bile embolism have been reported in patients with combined portal and hepatic vein trauma after ERCP and sphincterotomy, isolated portal vein cannulation, as in the current case, does not usually result in mortality or serious morbidity. However, awareness of this rare complication is important so that no further intervention is performed.

Repeated enteral stent fracture in patient with benign duodenal stricture

Self-expanding metal stents (SEMSs) are now widely used for palliation of malignant stricturing in the pyloric region as well as other parts of the GI tract. 1-5 There is limited literature about the benefits in benign gastric outlet obstruction. 6,7 We report the case of a patient with a benign pyloroduodenal stricture who was treated with enteral stenting for symptom relief complicated by the ingrowth of an uncovered stent and fracture of 2 covered metal stents.

Emergency Hospital Admission as a Route for Oesophagogastric Cancer Diagnosis: A Marker of Poor Outcome and a Candidate Quality Indicator for Local Services

Introduction The UK National Cancer Plan (2000) introduced a ‘two week’ waiting time standard for suspected malignancy and guidance to encourage early diagnosis. Improved access to elective ( ELECT ) investigation should reduce the need for emergency ( EMERG ) admission. This study examined route of diagnosis and outcomes for oesophagogastric cancer ( OGC ), both locally and nationally. Methods Local OGC cases were audited for 2-year periods before (‘ Pre’ : July 97–June 99) and after (‘ Post’ : Jan 01-Dec 02) service re-design, collecting details of demographics, tumour type, stage, dates of referral, diagnosis, treatment and survival. Within a project funded by the NHS Information Centre, we developed novel linkage algorithms to analyse Hospital Episode Statistics for England (2006–2008) and methods to track OGC care chronologically, selecting only incident cases with a valid pathway of coded diagnostic and therapeutic interventions. External linkage to death registry established date of death and 2-year survival. Results LOCAL DATA : n = 333 cases ( Pre , n = 152; Post , n = 181). No change in % of patients diagnosed via EMERG route after service re-design ( Pre : 30.9% vs Post : 31.5%; p = 0.981), nor any change in age, symptom or tumour profile of EMERG cases. Local EMERG cases were older than ELEC (75 vs 68 years; p EMERG cases with dysphagia and/or weight loss had lower 3 year survival than those with other presenting features (p = 0.035). NATIONAL DATA We identified 33,115 patients with OGC, of whom 26,097 (79%) met study criteria. Of these, 7082 (27%) were EMERG and 19,015 ELEC (73%). EMERG cases were older (74 years vs 70 years; p EMERG cases varied widely between cancer networks (22% to 40%). Conclusion Findings are consistent with a recent report by the National Cancer Intelligence Network (Nov 2010) suggesting that a quarter of major cancers are diagnosed via the EMERG route. Our national linkage study suggests 27% of new OGC cases in England are diagnosed as EMERG and this mode of presentation predicts a poor outcome, confirmed by detailed local audit. Although EMERG admission is unavoidable for some cases, the observed variation across the country suggests possible unresolved inequalities in patient access. Monitoring of this candidate indicator could assess the impact of new initiatives to promote earlier elective diagnosis.

PTH-111 Alpha-fetoprotein (afp) in hepatocellular carcinoma (hcc): determination of optimum cut-off value for prognosis

Introduction Whilst alpha feto-protein is secreted by some hepatocellular carcinoma, it is not recommended for diagnosis in current guidelines. It is well recognised as a marker of prognosis in hepatocellular carcinoma and therefore we aimed to determine an appropriate cut-off value that would provide optimal prognostic information for this cancer. Method Consecutive patients (n = 432) with valid alpha feto-protein measurements diagnosed with hepatocellular carcinoma during 2005 to 2014 in the Liverpool region, UK were included. The area under the receiver operating characteristic curve of alpha feto-protein by status of patients was used to determine the optimal cut-off. This value was then used to assess overall survival of the study population by type of treatment. The predictive performance of the new cut-off was assessed by its performance in the Hepatoma arterial-embolisation prognostic score of patients treated by trans-arterial chemoembolisation. Results Serum alpha feto-protein value, ≥43 ng/mL predicted prognosis (sensitivity 48% / specificity 78%) better than ≥400 ng/mL (sensitivity 28%/specificity 89%). The median survival was 28 months (95% CI: 21–33) in patients with AFP <43 ng/mL and 7 months (95% CI: 5–8) for those whose alpha feto-protein was ≥43 ng/mL. Also, accurate prediction of survival for hepatocellular carcinoma patients receiving loco-regional therapy (34 months vs. 14 months, p < 0.0001) and curative therapy (43 months vs. 15 months, p = 0.001) was obtained. Conclusion An alpha feto-protein of ≥43 was defined as the optimal cut-off to aid prognostic predictions. These results require external validation before recommendation for decision making in clinical practice. Disclosure of interest None Declared.

Mo1046 An External Validation of the Hepatoma Arterial-Embolisation Prognosis (Hap) Score: The Liverpool Experience

Introduction Most Hepatocellular Carcinomas (HCCs) have palliative treatment. Trans-arterial embolisation (TAE) or chemoembolisation (TACE) are used with variable results. The HAP score was recently described to determine patients likely to benefit from TAE or TACE. We report our experience with TAE and TACE to assess whether the HAP score was valid for our cohort of patients. Methods Retrospective review of cases given TAE or TACE in Liverpool, UK (2006–2013). HAP score [1 point each for albumin 400 ng/ml, Bilirubin > 17 µmol/l, tumour diameter > 7cm. HAP A = 0 points, B = 1, C = 2, D >2]. Outcome recorded according to HAP score. Results 137 patients identified having received TAE/TACE with full data to complete HAP score. Mean age 69; 116 (84.7%) male. 78.8% AUH, 21.2% RLUH. HAP score A: 44 (32.1%); B: 40 (29.2%); C: 32 (23.4%); D: 21 (15.3%). Overall median survival 492 days (16 months). Median survival by HAP score, A: 492 days; B: 839 days; C 478 days; D 309 days. Log rank p Conclusion Patients with HAP score D due TACE have a relatively poor outcome in this external validation group. This should be considered when planning treatment or further trials. Reference Kadalayil et al . Annals of Oncology 2013 Disclosure of Interest None Declared.

Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy

AIM To describe the efficacy and safety of endoscopic papillary large balloon dilatation (EPLBD) in the management of bile duct stones in a Western population. METHODS Data was collected from the endoscopic retrograde cholangiopancreatography (ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1st August 2009 to 31st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using MedCalc for Windows, version 12.5 (MedCalc Software, Ostend, Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore, we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05. RESULTS EPLBD was performed in 229 patients (46 females) with mean age of 68 ± 14.3 years. 115/229 (50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP (1st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81 (35.4%). Median balloon size was 13.5 mm (10 - 18). In addition to EPLBD, per-oral cholangioscopy (POC) and electrohydraulic lithotripsy (EHL) was performed in 35 (15%) patients at index* ERCP. 63 (27.5%) required repeat ERCP for stone clearance. 28 (44.5%) required POC and EHL and 11 (17.4%) had repeat EPLBD for complete duct clearance. Larger stone size (12.4 mm vs 17.4 mm, P < 0.000001), multiple stones (2, range (1-13) vs 3, range (1-12), P < 0.006) and dilated common bile duct (CBD) (12.4 mm vs 18.3 mm, P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients (20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of bleeding and pancreatitis (0.87%) each. CONCLUSION EPLBD is a safe and effective technique for CBDS removal. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy.

PTH-012 ERCP Training – Achieving Better Outcomes for Patients and Trainees through A New Training Guide

Introduction It is acknowledged that ERCP is challenging to train both for the trainers and the trainees. Recent evidence has suggested that a much longer period of focused training is required to achieve competence, particularly cannulation of the native ampulla.1 There is also significant variability in training and performance. Unlike other endoscopic interventions, such as colonoscopy there is a lack of coherent strategy to guide training. The traditional model is unstructured and intuitive, largely conforming to the notion of ‘start the trial at the incisors and continue until failure’ at which point the trainers take over the scope to complete the procedure. Our model identifies a range of individual skills that can be developed in a structured manner.Abstract PTH-012 Figure 1 Methods Our model in practice, was borne of multiple informal focus groups involving experienced and training ERCPists, both in service and in training courses. Results Our model of graded progression in ERCP training takes into account the broadly agreed complexity of the each skill set in a deconstructed ERCP.We allocate skills to 4 different domains of increasing complexity, which requires increasing dexterity and cognitive awareness from the endoscopist. In each procedure the trainee would have the opportunity to gain exposure to aspects of ERCP that is appropriate to the stage/level of training, gradually moving along a spectrum of skills of increasing complexity, associated with higher risk of complications. Such a graded progression ensures that the trainee is set up to learn each increasing complex skill with appropriate level of preparedness, enabling smoother progression in training. Trainees are assessed every 10 ERCP for progression. An example of an ERCPist at early stage of training (Pic A) is as shown below. Conclusion Our training guide could be a component of much needed structure to drive streamlined ERCP training in UK. Adoption of the guide or similar will enable enhanced continuity in training when trainees move between training centres, from initiation to independence. Reference 1 Verma D, et al. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc. 2007. Disclosure of Interest None Declared

PTH-113 Factors affecting survival outcomes in patients with cholangiocarcinoma – a uk regional hepato-biliary centre experience

Introduction The incidence and mortality of Intrahepatic bile duct cholangiocarcinoma (CCA) has risen worldwide over the past few decades. Over the last four decades, an exponential rise in the age-standardised mortality rate of CCA has been recorded in England and Wales. We examined the factors affecting survival from CCA at a regional hepato-biliary centre. Method We retrospectively reviewed 340 patients with confirmed CCA to evaluate the factors affecting survival over a period of six years (2009–2014). The hospital integrated data base was used for clinical, radiological, histological and endoscopic details. Overall survival by modality of treatment was examined by Kaplan-Meier log rank test. Factors contributing to mortality were assessed by Cox proportional hazards. Results There was a female preponderance of CCA (n = 174, 51.2%), histology being the most prevalent mode of diagnosis (n = 154, 45.3%) and palliative biliary stenting most utilised treatment (n = 171, 50.3%). Intrahepatic CCA had the largest tumour diameter versus extrahepatic CCA (median: 6.2 cm vs 3.0 cm, p= <0.0001). Overall median survival was 8 months (range 7–11). The median survival for those treated with chemotherapy, biliary stent and best supportive care were 16 (11–18), 5 (4–6) and 4 (2–7) months, respectively. 5 year survival post resection was 80%. Surgical resection and chemotherapy were associated with improved survival (HR: 0.13; 95% CI: 0.06–0.28, p < 0.0001) and (HR: 0.33; 95% CI: 0.17–0.60, p = 0.0003) respectively, whereas the presence of biliary calculi at diagnosis conferred a negative impact on survival (HR: 1.83; 95% CI: 1.19–2.81, p = 0.006). Presence of biliary calculi was a significant independent predictor of survival in patients with hilar CCA. Conclusion Similar to experience elsewhere, we observed that surgical resection and chemotherapy offered survival benefit to CCA patients. The association of increased mortality in presence of biliary calculi prompts further prospective investigation of the possibility that the diagnosis of stone disease delays recognition of coexisting bile duct tumours. Disclosure of interest None Declared.