The Impact of Acute Systemic Inflammation Secondary to Oesophagectomy and Anastomotic Leak on Computed Tomography Body Composition Analyses.

This study aimed to longitudinally assess CT body composition analyses in patients who experienced anastomotic leak post-oesophagectomy. Consecutive patients, between 1 January 2012 and 1 January 2022 were identified from a prospectively maintained database. Changes in computed tomography (CT) body composition at the third lumbar vertebral level (remote from the site of complication) were assessed across four time points where available: staging, pre-operative/post-neoadjuvant treatment, post-leak, and late follow-up. A total of 20 patients (median 65 years, 90% male) were included, with a total of 66 computed tomography (CT) scans analysed. Of these, 16 underwent neoadjuvant chemo(radio)therapy prior to oesophagectomy. Skeletal muscle index (SMI) was significantly reduced following neoadjuvant treatment (p < 0.001). Following the inflammatory response associated with surgery and anastomotic leak, a decrease in SMI (mean difference: -4.23 cm2/m2, p < 0.001) was noted. Estimates of intramuscular and subcutaneous adipose tissue quantity conversely increased (both p < 0.001). Skeletal muscle density fell (mean difference: -5.42 HU, p = 0.049) while visceral and subcutaneous fat density were higher following anastomotic leak. Thus, all tissues trended towards the radiodensity of water. Although tissue radiodensity and subcutaneous fat area normalised on late follow-up scans, skeletal muscle index remained below pre-treatment levels.

A predictive Bayesian network that risk stratifies patients undergoing Barrett's surveillance for personalized risk of developing malignancy.

BACKGROUND: Barrett's esophagus is strongly associated with esophageal adenocarcinoma. Considering costs and risks associated with invasive surveillance endoscopies better methods of risk stratification are required to assist decision-making and move toward more personalised tailoring of Barrett's surveillance. METHODS: A Bayesian network was created by synthesizing data from published studies analysing risk factors for developing adenocarcinoma in Barrett's oesophagus through a two-stage weighting process. RESULTS: Data was synthesized from 114 studies (n = 394,827) to create the Bayesian network, which was validated against a prospectively maintained institutional database (n = 571). Version 1 contained 10 variables (dysplasia, gender, age, Barrett's segment length, statin use, proton pump inhibitor use, BMI, smoking, aspirin and NSAID use) and achieved AUC of 0.61. Version 2 contained 4 variables with the strongest evidence of association with the development of adenocarcinoma in Barrett's (dysplasia, gender, age, Barrett's segment length) and achieved an AUC 0.90. CONCLUSION: This Bayesian network is unique in the way it utilizes published data to translate the existing empirical evidence surrounding the risk of developing adenocarcinoma in Barrett's esophagus to make personalized risk predictions. Further work is required but this tool marks a vital step towards delivering a more personalized approach to Barrett's surveillance.

Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis.

BACKGROUND: The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches. METHODS: An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct. RESULTS: Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00-0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01-0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%). CONCLUSION: One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.

Pre-diagnostic delays caused by gastrointestinal investigations do not affect outcomes in pancreatic cancer.

BACKGROUND: Pancreatic ductal adenocarcinomas are poor prognostic cancers accounting for 3% of all cancer cases in the UK. They often present late in the course of the disease process with non-specific symptoms, including gastro-intestinal(GI) symptoms. Delays in diagnosis occur when investigations are carried out in a primary care setting for GI symptoms. The aim of this study was to assess delays in pancreatic cancer diagnosis when patients were referred for GI investigations and evaluate its effect on survival. METHODS: Retrospective cohort study of all patients diagnosed with pancreatic adenocarcinoma in a Scottish district general hospital over a seven year period from January 2010 to December 2016. Patients were divided into two groups, those who had a GI investigation 18 months prior to the pancreatic cancer diagnosis and those who did not have GI investigations. Data on demographics, symptoms on referral, stage of disease at diagnosis, treatment undergone and length of survival collected and analysed. RESULTS: One hundred and fifty-three patients were diagnosed with pancreatic cancer in the study period. Forty (26%) of the 153 underwent gastrointestinal investigations in the 18 months prior to diagnosis. The remaining 113 (74%) had no gastro-intestinal investigations in the same time period. Demographic data were comparable. Significant delays occurred from referral to diagnosis in the GI investigated group compared to those who did not have GI investigations. (64.5days vs 9 days, p = 0.001). No difference was noted in disease stage or treatments undergone between the groups. There was no difference in the average survival after diagnosis between the two groups with median of 108 days for those who underwent GI investigations to 97 days for those who did not.(U = 2079.5, p = 0.454). CONCLUSION: Delays caused by pre-diagnostic GI investigations do not appear to contribute to the poor prognosis of pancreatic cancer. Recently updated NICE Guidelines recommends early ultrasound or CT in patients with GI symptoms and weight loss which may reduce delays in diagnosis. Screening tests in future may become cost effective and diagnose this condition at a curable stage which in turn may improve survival rates.