SCANPatient: study protocol for a multi-centre, batched, stepped wedge, comparative effectiveness, randomised clinical trial of synoptic reporting of computerised tomography (CT) scans assessing cancers of the pancreas.

BACKGROUND: Complete surgical removal of pancreatic ductal adenocarcinoma (PDAC) is central to all curative treatment approaches for this aggressive disease, yet this is only possible in patients technically amenable to resection. Hence, an accurate assessment of whether patients are suitable for surgery is of paramount importance. The SCANPatient trial aims to test whether implementing a structured synoptic radiological report results in increased institutional accuracy in defining surgical resectability of non-metastatic PDAC. METHODS: SCANPatient is a batched, stepped wedge, comparative effectiveness, cluster randomised clinical trial. The trial will be conducted at 33 Australian hospitals all of which hold regular multi-disciplinary team meetings (MDMs) to discuss newly diagnosed patients with PDAC. Each site is required to manage a minimum of 20 patients per year (across all stages). Hospitals will be randomised to begin synoptic reporting within a batched, stepped wedge design. Initially all hospitals will continue to use their current reporting method; within each batch, after each 6-month period, a randomly selected group of hospitals will commence using the synoptic reports, until all hospitals are using synoptic reporting. Each hospital will provide data from patients who (i) are aged 18 or older; (ii) have suspected PDAC and have an abdominal CT scan, and (iii) are presented at a participating MDM. Non-metastatic patients will be documented as one of the following categories: (1) locally advanced and surgically unresectable; (2) borderline resectable; or (3) anatomically clearly resectable (Note: Metastatic disease is treated as a separate category). Data collection will last for 36 months in each batch, and a total of 2400 patients will be included. DISCUSSION: Better classifying patients with non-metastatic PDAC as having tumours that are either clearly resectable, borderline or locally advanced and unresectable may improve patient outcomes by optimising care and treatment planning. The borderline resectable group are a small but important cohort in whom surgery with curative intent may be considered; however, inconsistencies with definitions and an understanding of resectability status means these patients are often incorrectly classified and hence overlooked for curative options. TRIAL REGISTRATION: The SCANPatient trial was registered on 17th May 2023 in the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12623000508673).

Experimental evaluation of accuracy and efficiency of two control strategies for a novel foot commanded robotic laparoscope holders with surgeons.

The implementation of a laparoscope-holding robot in minimally invasive surgery enhances the efficiency and safety of the operation. However, the extra robot control task can increase the cognitive load on surgeons. A suitable interface may simplify the control task and reduce the surgeon load. Foot interfaces are commonly used for commanding laparoscope-holding robots, with two control strategies available: decoupled control permits only one Cartesian axis actuation, known as decoupled commands; hybrid control allows for both decoupled commands and multiple axes actuation, known as coupled commands. This paper aims to determine the optimal control strategy for foot interfaces by investigating two common assumptions in the literature: (1) Decoupled control is believed to result in better predictability of the final laparoscopic view orientation, and (2) Hybrid control has the efficiency advantage in laparoscope control. Our user study with 11 experienced and trainee surgeons shows that decoupled control has better predictability than hybrid control, while both approaches are equally efficient. In addition, using two surgery-like tasks in a simulator, users' choice of decoupled and coupled commands is analysed based on their level of surgical experience and the nature of the movement. Results show that trainee surgeons tend to issue more commands than the more experienced participants. Single decoupled commands were frequently used in small view adjustments, while a mixture of coupled and decoupled commands was preferred in larger view adjustments. A guideline for foot interface control strategy selection is provided.

Registry-derived stage (RD-Stage) for capturing stage at diagnosis for pancreatic carcinoma in Australia.

INTRODUCTION: Stage of pancreatic carcinoma at diagnosis is a strong prognostic indicator of morbidity and mortality, yet is poorly notified to population-based cancer registries ("cancer registries"). Registry-derived stage (RD-Stage) provides a method for cancer registries to use available data sources to compile and record stage in a consistent way. This project describes the development and validation of rules to capture RD-Stage (pancreatic carcinoma) and applies the rules to data currently captured in each Australian cancer registry. MATERIALS AND METHODS: Rules for deriving RD-stage (pancreatic carcinoma) were developed using the American Joint Commission on Cancer (AJCC) Staging Manual 8th edition and endorsed by an Expert Working Group comprising specialists responsible for delivering care to patients diagnosed with pancreatic carcinoma, cancer registry epidemiologists and medical coders. Completeness of data fields required to calculate RD-Stage (pancreatic carcinoma) and an overall proportion of cases for whom RD stage could be assigned was assessed using data collected by each Australian cancer registry, for period 2018-2019. A validation study compared RD-Stage (pancreatic carcinoma) calculated by the Victorian Cancer Registry with clinical stage captured by the Upper Gastro-intestinal Cancer Registry (UGICR). RESULTS: RD-Stage (pancreatic carcinoma) could not be calculated in 4/8 (50%) of cancer registries; one did not collect the required data elements while three used a staging system not compatible with RD-Stage requirements. Of the four cancer registries able to calculate RD-Stage, baseline completeness ranged from 9% to 76%. Validation of RD-Stage (pancreatic carcinoma) with UGICR data indicated that there was insufficient data available in VCR to stage 174/457 (38%) cases and that stage was unknown in 189/457 (41%) cases in the UGICR. Yet, where it could be derived, there was very good concordance at stage level (I, II, III, IV) between the two datasets. (95.2% concordance], Kendall's coefficient = 0.92). CONCLUSION: There is a lack of standardisation of data elements and data sources available to cancer registries at a national level, resulting in poor capacity to currently capture RD-Stage (pancreatic carcinoma). RD-Stage provides an excellent tool to cancer registries to capture stage when data elements required to calculate it are available to cancer registries.

A rare case of MRI of myxoid hepatocellular adenoma with gadoxetic acid uptake.

This is the first case report of 43-year-old lady with a myxoid hepatic adenoma which demonstrated significant contrast uptake during hepatobiliary phase imaging. This highlights the potential for a missed diagnosis and likely subsequent malignant transformation in a young patient in whom it was initially presumed to be focal nodular hyperplasia with no further surveillance.

Characteristics of patients diagnosed with pancreatic cancer who access palliative care: An observational study.

PURPOSE: Despite the benefits of palliative care (PC) in pancreatic cancer, little is known about patients who access PC. This observational study examines the characteristics of patients with pancreatic cancer at their first episode of PC. METHODS: First-time, specialist PC episodes captured through the Palliative Care Outcomes Collaboration (PCOC), in Victoria, Australia between 2014 and 2020, for pancreatic cancer, were identified. Multivariable logistic regression analyses examined the impact of patient- and service-level characteristics on symptom burden (measured through patient-reported outcome measures and clinician-rated scores) at first PC episode. RESULTS: Of 2890 eligible episodes, 45% began when the patient was deteriorating and 32% ended in death. High fatigue and appetite-related distress were most common. Generally, increasing age, higher performance status and more recent year of diagnosis predicted lower symptom burden. No significant differences were noted between symptom burden of regional/remote versus major city dwellers; however, only 11% of episodes recorded the patient as a regional/remote resident. A greater proportion of first episodes for non-English-speaking patients began when the patient was unstable, deteriorating or terminal, ended in death and were more likely to be associated with high family/carer problems. Community PC setting predicted high symptom burden, with the exception of pain. CONCLUSION: A large proportion of first-time specialist PC episodes in pancreatic cancer begin at a deteriorating phase and end in death, suggesting late access to PC. Timely referrals to community-based specialist PC, access in regional/remote areas, as well as development of culturally diverse support systems require further investigation.

Changing patterns of care for pancreas cancer in Victoria: the 2022 Pancreas Tumour Summit.

BACKGROUND: The Victorian Government convened the second Pancreas Cancer Summit in 2021 to identify unwarranted variation in care 2016-2019, and to assess trends compared with the first Summit 2017 (reporting 2011-2015). State-wide administrative data were assessed at population level in alignment with optimal care pathways across all stages of the cancer care continuum. METHODS: Data linkage performed by Centre for Victorian Data Linkage combined data from Victorian Cancer Registry with other administrative data sets including Victorian Admitted Episodes Dataset, Victorian Radiotherapy Minimum Data Set, Victorian Emergency Minimum Dataset and Victorian Death Index. A Cancer Service Performance Indicator audit was carried out providing an in-depth analysis of identified areas of interest. RESULTS: Of 3138 Victorians diagnosed with pancreas ductal adenocarcinoma 2016-2019, 63% were metastatic at diagnosis. One-year survival increased between time periods, from 29.7% overall 2011-2015 (59.1% for non-metastatic, and 15.1% metastatic) to 32.5% overall 2016-2019 (P < 0.001), 61.2% non-metastatic (P = 0.008), 15.7% metastatic (P = NS). A higher proportion of non-metastatic patients progressed to surgery (35% vs. 31%, P = 0.020), and more received neoadjuvant therapy (16% vs. 4%, P < 0.001). Postoperative mortality following pancreatectomy at 30 and 90 days remained low at 2%. Utilization of 5FU-based chemotherapy regimens increased between 2016 and 2020. Multidisciplinary Meeting (MDM) presentation was still below the 85% target (74%) as was supportive care screening (39%, target 80%). CONCLUSIONS: Surgical outcomes remain world-class and there has been an appropriate shift in chemotherapy administration towards neoadjuvant timing with increasing use of 5FU-based regimens. MDM presentation rates, supportive care and overall care coordination remain areas of deficiency.

Surgical management of injured ADF personnel deployed to Afghanistan 2001-2021.

INTRODUCTION: A comprehensive review of the surgical management of injuries sustained by deployed members of the Australian Defence Force (ADF) during Operation SLIPPER and HIGHROAD in Afghanistan has not previously been undertaken. Understanding the mechanism of injury, injury types sustained and surgical intervention undertaken should provide valuable information for future health planning and surgical capability determination. METHODS: Retrospective chart review of scanned medical records of injured personnel identified through casualty register examination was undertaken. RESULTS: There were 259 ADF personnel injured in Afghanistan between January 2002 and December 2021, of which 53 were seriously (SI), or very seriously injured (VSI). Case notes for 90 of 101 casualties including those sustaining VSI, SI and those classified as being in satisfactory condition, but likely requiring surgery and/or returned to Australia following trauma, were available for review. Most patients with VSI/SI required surgery (93%) and most were returned to Australia following injury (91%). Almost two-thirds (64.4%) of initial surgery was undertaken at a Role 2 E medical treatment facility (MTF). Gun-shot wound (GSW) was the commonest injuring mechanism (47%) followed by blast injury (39.6%). Orthopaedic (32.2%) and soft tissue initial wound surgery (47.1%) were the commonest surgical procedures. DISCUSSION: Surgical management of military trauma was undertaken at multiple sites by multiple surgical teams from different nationalities delivering exceptional results and conforming to modern principles of damage control surgery. The military trauma system is distinctly different from its civilian counterpart with dispersion of assets requiring multiple episodes of casualty movement between echelons of care rather than centralization at level 1 trauma centres. Despite this, excellent results are achievable. Strengthening lines of communication and documentation would reinforce the ability of the military trauma system to continue to provide such results, and regular oversight and review of surgical caseload would align military trauma surgery with civilian standards. The benchmark set by the United States Department of Defense Trauma Registry should be replicated for Australian led combat operations and modified to facilitate interoperability to support future coalition combat operations.

Synoptic CT scan reporting of pancreatic adenocarcinoma to align with international consensus guidelines on surgical resectability: a Victorian pilot.

BACKGROUND: Non-metastatic pancreatic ductal adenocarcinoma (PDAC) is classified as resectable (R), borderline resectable (BR) or locally advanced (LA). International Consensus Guidelines on these definitions exist, but have not been integrated into everyday Australian practice. The anatomical features on CT imaging lend themselves to synoptic reporting which should enhance completeness, comparability and consistency. METHODS: We developed and tested a synoptic report for PDAC derived from the International Consensus Guidelines at two metropolitan pancreatic cancer services to standardize CT reporting in the region. Consecutive scans with suspected PDAC discussed at multidisciplinary meetings were reported using the template between October 2020 and September 2021. A purpose-built database captured data regarding resectability and image-quality parameters. RESULTS: Ninety-five scans were reviewed, 57.9% (N = 55) of which conformed to high-quality pancreatic CT protocols. Of suboptimal scans, meaningful synoptic reports were able to be issued for a further 24/40 (due to metastases in 9, and unequivocal resectability status in 15). Of 79 classifiable scans, 20% were metastatic, 51% deemed resectable, 16% locally advanced and 13% borderline resectable. DISCUSSION: PDAC lends itself to synoptic reporting given the specific anatomical considerations that classify resectability. This relies, however, on high-quality CT imaging and it was surprising that over 40% of scans reviewed were of suboptimal quality. Despite this, resectability status according to the International Consensus Guidelines was designated for 83% of scans. Optimal treatment algorithms for LA, BR and resectable disease vary widely underscoring the critical importance of accurately differentiating these anatomic subtypes of PDAC, and thus support further implementation of a synoptic report of this nature.

Systematic review of the predictors of health service use in pancreatic cancer.

INTRODUCTION: Pancreatic cancer (PC) has a dismal prognosis, with identified disparities in survival outcomes based on demographic characteristics. These disparities may be ameliorated by equitable access to treatments and health services. This systematic review identifies patient and service-level characteristics associated with PC health service utilisation (HSU). METHODS: Medline, Embase, CINAHL, PsycINFO and Scopus were systematically searched between 1st January, 2010 and 17 May, 2021 for population-based, PC studies which conducted univariable and/or multivariable regression analyses to identify patient and/or service-level characteristics associated with use of a treatment or health service. Direction of effect sizes were reported in an aggregate manner. RESULTS: Sixty-two eligible studies were identified. Most (48/62) explored the predictors of surgery (n=25) and chemotherapy (n=23), and in populations predominantly based in the United States of America (n=50). Decreased HSU was observed among people belonging to older age groups, non-Caucasian ethnicities, lower socioeconomic status (SES) and lower education status. Non-metropolitan location of residence predicted decreased use of certain treatments, and was associated with reduced hospitalisations. People with comorbidities were less likely to use treatments and services, including specialist consultations and palliative care but were more likely to be hospitalised. A more recent year of diagnosis/year of death was generally associated with increased HSU. Academically affiliated and high-volume centres predicted increased treatment use and hospital readmissions. CONCLUSION: Findings of this review may assist identification of vulnerable patient groups experiencing disparities in accessing and using treatments and therapies.

Prognostic models to predict survival in patients with pancreatic cancer: a systematic review.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has poor survival. Current treatments offer little likelihood of cure or long-term survival. This systematic review evaluates prognostic models predicting overall survival in patients diagnosed with PDAC. METHODS: We conducted a comprehensive search of eight electronic databases from their date of inception through to December 2019. Studies that published models predicting survival in patients with PDAC were identified. RESULTS: 3297 studies were identified; 187 full-text articles were retrieved and 54 studies of 49 unique prognostic models were included. Of these, 28 (57.1%) were conducted in patients with advanced disease, 17 (34.7%) with resectable disease, and four (8.2%) in all patients. 34 (69.4%) models were validated, and 35 (71.4%) reported model discrimination, with only five models reporting values >0.70 in both derivation and validation cohorts. Many (n = 27) had a moderate to high risk of bias and most (n = 33) were developed using retrospective data. No variables were unanimously found to be predictive of survival when included in more than one study. CONCLUSION: Most prognostic models were developed using retrospective data and performed poorly. Future research should validate instruments performing well locally in international cohorts and investigate other potential predictors of survival.

A qualitative investigation of the supportive care experiences of people living with pancreatic and oesophagogastric cancer.

BACKGROUND: Pancreatic and oesophagogastric (OG) cancers have a dismal prognosis and high symptom burden, with supportive care forming an integral component of the care provided to patients. This study aimed to explore the supportive care experiences of patients and caregivers living with pancreatic and OG cancers in order to identify perceived opportunities for improvement. METHODS: Semi-structured individual interviews were conducted with people living with pancreatic and OG cancers, and their caregivers, across Victoria, Australia during 2020. Interviews were thematically analysed to identify common themes. RESULTS: Forty-one participants were interviewed, including 30 patients and 11 caregivers. Three overarching themes, each with multiple sub-themes, were identified: (i) inadequate support for symptoms and issues across the cancer journey (ii) caregiver's desire for greater support, and (iii) a multidisciplinary care team is the hallmark of a positive supportive care experience. Generally, those who had access to a cancer care coordinator and/or a palliative care team recounted more positive supportive care experiences. CONCLUSION: Unmet needs are prevalent across the pancreatic and OG cancer journey, with supportive care provided to varying levels of satisfaction. Greater awareness of and access to high-quality multidisciplinary support services is greatly desired by both patients with pancreatic and OG cancer and their caregivers.

The impact of COVID-19 on emergency cholecystectomy.

BACKGROUNDS: The impact of the SARS-CoV-2 virus (COVID-19) upon the delivery of surgical services in Australia has not been well characterized, other than restrictions to elective surgery due to government directive-related cancellations. Using emergency cholecystectomy as a representative operation, this study aimed to investigate the impact of COVID-19 on emergency general surgery in Australia in relation to in-hours versus after-hours operating. METHODS: A retrospective analysis was conducted of medical records for patients admitted with cholecystitis or biliary colic between 1 March 2019 and 28 February 2021 at Frankston Hospital, Australia. Patient demographics, admission data, imaging findings, operative and post-operative data were compared between pre-COVID-19 and COVID-19 periods. Variables were compared using the Wilcoxon-Mann-Whitney, Chi Squared or Fishers exact test. RESULTS: During the COVID-19 period, emergency cholecystectomy was performed for a greater proportion of patients presenting with cholecystitis or biliary colic (93.5% versus 77.7%, p < 0.01). Despite this, there was concomitant reduction in after-hours cholecystectomy from 14.4% to 7.5% (p = 0.04). Patients requiring after-hours surgery during the COVID-19 period had more features of sepsis (23% more tachypnoeic, 18% more hypotensive), and were more likely to have certain features of cholecystitis on imaging (45% more likely to have pericholecystic fluid). CONCLUSION: Following elective surgery cancellations during the COVID-19 period, an increase was seen in the proportion of patients presenting with gallstone disease who were managed with emergency cholecystectomy due to improved theatre access. Concurrently, there was a decrease in the requirement for surgery to be performed after-hours.

The association between quality care and outcomes for a real-world population of Australian patients diagnosed with pancreatic cancer.

BACKGROUND: This study: (i) assessed compliance with a consensus set of quality indicators (QIs) in pancreatic cancer (PC); and (ii) evaluated the association between compliance with these QIs and survival. METHODS: Four years of data were collected for patients diagnosed with PC. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). A multivariable analysis tested the relationship between significant patient and hospital characteristics, patient cluster effects within hospitals and survival. RESULTS: 1061 patients were eligible for this study. Significant association with improved survival were: (i) in the potentially resectable group having adjuvant chemotherapy administered following surgery or a reason documented (HR, 0.29; 95 CI, 0.19-0.46); (ii) in the locally advanced group included having chemotherapy ± chemoradiation, or a reason documented for not undergoing treatment (HR, 0.38; 95 CI, 0.25-0.58); and (iii) in the metastatic disease group included having documented performance status at presentation (HR, 0.65; 95 CI, 0.47-0.89), being seen by an oncologist in the absence of treatment (HR, 0.48; 95 CI, 0.31-0.77), and disease management discussed at a multidisciplinary team meeting (HR, 0.79; 95 CI, 0.64-0.96). CONCLUSION: Capture of a concise data set has enabled quality of care to be assessed.

A Novel Perception Framework for Automatic Laparoscope Zoom Factor Control Using Tool Geometry.

In conventional Minimally Invasive Surgery, the surgeon conducts the operation while a human or robot holds the laparoscope. Laparoscope control is returned to the surgeon in teleoperated camera holding robots, but simultaneously controlling the laparoscope and surgical tools might be cognitively demanding. On the other hand, fully automated camera holders are still limited in their performance. To help the surgeon to better focus on the main operation while maintaining their control authority, we propose an automatic laparoscope zoom factor control framework for Robot-Assisted Minimally Invasive Surgery. In this paper, we present the perception section of the framework. It extracts and uses the surgical tool's geometric characteristics to adjust the laparoscope's zoom factor, without any artificial markers. The acceptable range and tooltip's position frequency during operations are analysed based on the gallbladder removal surgery dataset (Cholec80). The common range and tooltip's heatmap are identified and presented quantitatively.

Low muscularity increases the risk for post-operative pneumonia and delays recovery from complications after oesophago-gastric cancer resection.

BACKGROUND: Low muscularity is associated with adverse surgical outcomes. We aimed to determine whether low muscularity is associated with an increased risk of post-operative complications and reduced long-term survival after oesophago-gastric cancer surgery. METHODS: Patients who underwent radical oesophago-gastric cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Low skeletal muscle index (SMI), measured by CT, was determined using pre-defined cut-points. Oncological, surgical, complications and outcome data were obtained from a prospective database. RESULTS: Of 108 patients, 61% (n = 66) had low SMI preoperatively. Patients with low SMI had a higher rate of post-operative pneumonia (30 vs. 7% normal muscularity, P = 0.004). Median length of stay (LOS) was higher in patients with low SMI if they had any complication (19.5 vs. 14 days, P = 0.026) or pneumonia (21 vs. 13 days, P = 0.018). On multivariate analysis, low SMI (OR 3.85, CI 1.10-13.4, P = 0.025), preoperative weight loss (OR 1.13, CI 1.01-1.25, P = 0.027), and smoking (OR 5.08, CI 1.24-20.9, P = 0.024) were independent predictors of having a severe complication. There was no difference in 5-year overall (62% vs. 69%, P = 0.241) and disease-free (11% vs. 21.4%, P = 0.110) survival between low SMI and normal muscle mass groups. CONCLUSION: Low SMI is associated with a significantly increased risk of pneumonia and increased LOS for patients with complications. Assessment of muscle mass may require additional muscle quality, strength, and physical performance measures to enhance preoperative risk assessment.

The EUS molecular evaluation of pancreatic cancer: A prospective multicenter cohort trial.

BACKGROUND AND OBJECTIVES: Patients with locally advanced or metastatic pancreatic ductal adenocarcinoma (A-PDAC) are not candidates for surgical resection and are often offered palliative chemotherapy. The ready availability of a safe and effective tumor sampling technique to provide material for both diagnosis and comprehensive genetic profiling is critical for informing precision medicine in A-PDAC, thus potentially increasing survival. The aim of this study is to examine the feasibility and benefits of routine comprehensive genomic profiling (CGP) of A-PDAC using EUS-FNA material. METHODS: This is a prospective cohort study to test the clinical utility of fresh frozen or archival EUS-FNA samples in providing genetic material for CGP. The results of the CGP will be reviewed at a molecular tumor board. The proportion of participants that have a change in their treatment recommendations based on their individual genomic profiling will be assessed. Correlations between CGP and stage, prognosis, response to treatment and overall survival will also be investigated. This study will open to recruitment in 2020, with a target accrual of 150 A-PDAC patients within 36 months, with a 2-year follow-up. It is expected that the majority of participants will be those who have already consented for their tissue to be biobanked in the Victorian Pancreatic Cancer Biobank at the time of diagnostic EUS-FNA. Patients without archival or biobanked material that is suitable for CGP may be offered a EUS-FNA procedure for the purposes of obtaining fresh frozen material. DISCUSSION: This trial is expected to provide crucial data regarding the feasibility of routine CGP of A-PDAC using EUS-FNA material. It will also provide important information about the impact of this methodology on patients' survival.

Metal stents are safe and cost-effective for preoperative biliary drainage in resectable pancreaticobiliary tumours.

BACKGROUNDS: To compare the complication rates and overall costs of self-expandable metal stents (SEMS) and plastic stents (PS) in clinically indicated preoperative biliary drainage (PBD) prior to a pancreatoduodenectomy (PD). METHODS: We conducted an Australian multicentre retrospective cohort study using the databases of four tertiary hospitals. Adult patients who underwent clinically indicated endoscopic PBD prior to PD from 2010 to 2019 were included. Rates of complications attributable to PBD, surgical complications and pre-operative endoscopic re-intervention were calculated. Costing data were retrieved from our Financial department. RESULTS: Among the 157 included patients (mean age 66.6 ± 9.8 years, 45.2% male), 49 (31.2%) received SEMS and 108 received PS (68.8%). Baseline bilirubin was 187.5 ± 122.6 µmol/L. Resection histopathology showed mainly adenocarcinoma (93.0%). Overall SEMS was associated less complications (12.2% vs. 28.7%, p = 0.02) and a lower pre-operative endoscopic re-intervention rate (4.3 vs. 20.8%, p = 0.03) compared with PS. There was no difference in post-PD complication rates. On multivariate logistic regression analysis, stent type was an independent risk factor of PBD complication (OR of SEMS compared to PS 0.24, 95% CI 0.07-0.79, p = 0.02) but not for any secondary outcome measures. Upfront material costs were $56USD for PS and $1991USD for SEMS. Accounting for rates of complications, average costs were similar ($3110USD for PS and $3026USD for SEMS). CONCLUSION: In resectable pancreaticobiliary tumours, SEMS for PBD was associated with reduced risk of overall PBD-related complications and pre-surgical endoscopic reintervention rates and was comparable to PS in terms of overall cost.

Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery.

INTRODUCTION: Low muscle attenuation, as governed by increased intramuscular fat infiltration (myosteatosis), may associate with adverse surgical outcomes. We aimed to determine whether myosteatosis is associated with an increased risk of postoperative complications and reduced long-term survival after oesophago-gastric (OG) cancer surgery. METHODS: Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Myosteatosis was evaluated using previously defined cut-points for low skeletal muscle attenuation measured by CT. Oncological, surgical, complications, and outcome data were obtained from a prospective database. RESULTS: Of 108 patients, 56% (n = 61) had myosteatosis. Patients with myosteatosis were older (69.1 ±â€¯9.1 vs. 62.8 ±â€¯9.8 years, p = 0.001) and had a similar body mass index (BMI) (23.4 ±â€¯5.3 vs. 25.9 ±â€¯6.7 kg/m2, p = 0.766) compared to patients with normal muscle attenuation. Patients with myosteatosis had a higher rate of anastomotic leaks (15% vs. 2%, p = 0.041). On multivariate analysis, myosteatosis was an independent predictor of overall (OR 3.03, 95% CI 1.31-6.99, p = 0.009) and severe complications (OR 4.33, 95% CI 1.26-14.9, p = 0.020). Patients with myosteatosis had reduced 5 year overall (54.1% vs. 83%, p = 0.004) and disease-free (55.2% vs. 87.2%, p = 0.007) survival. CONCLUSION: Myosteatosis is associated with a significantly increased risk of overall and severe complications as well as substantially reduced long-term survival. Assessment of muscle attenuation provides analysis beyond standard anthropometrics and may form part of preoperative physiological staging tools used to improve surgical outcomes.