P-OGC53 Dashboarding for real-time analysis of oesophagogastric outcomes data

Background The typical paradigm for surgical service evaluation is intermittent audit based on perceived clinical need and mandated requirements. A better model would be monitoring patient outcomes automatically in real-time, with up-to-date cumulative frequencies of key surgical performance indicators such as surgical quality and morbidity, as changes in performance could be detected and reacted to at an earlier stage. This study aimed to develop a dashboarding technology to support real-time visualisation of prospectively maintained oesophagogastric cancer surgery data. Methods CODA is a bespoke databank (implemented in MS SQL Server, with HTML, C# and JavaScript) for oesophagogastric cancer care at our centre. We built on a custom dashboard interface for displaying this information in real-time, using Shiny for R and Tableau. We identified the key performance indicators (KPIs) to monitor in the dashboard, and defined benchmarks based on accepted standards, or our prevailing performance (based on 448 consecutive patients who underwent oesophagectomy between 2015 – 2020). The domains selected were surgical quality, length of stay, early mortality, and priority complications. Complications were defined according to the Esophagectomy Complications Consensus Group. Results For surgical quality, our benchmarks based on prevailing performance were (i) >90% >15 lymph node yield (ii) <2-5% longitudinal R1 (iii) <20-30% CRM R1. For length of stay, our benchmarks were (i) >33% meeting 8 day discharge target (ii) <15% missing target discharge without a medical complication (iii) <20% staying longer than two weeks. For 30 & 90 day mortality, our benchmarks were 2% and 4% respectively. For complications, two sets were identified: (i) common complications (occurring at > 2 / year, monitored 2-yearly) (ii) impactful complications (>1 / year, >1 week median additional stay, monitored 5-yearly) Conclusions The CODA dashboard provides real-time appraisal of oesophagogastric cancer surgery practice, highlighting changes in performance and providing opportunity for early intervention. The platform can be used for personal, departmental or inter-institutional service evaluation. The KPIs will be extended to oesophagogastric cancer survival as the test set matures. The interface and wider benefits of CODA implementation are presented, together with the dissemination plan for use in other oesophagogastric centres.

P-OGC80 The effect of COVID -19 on new diagnosis oesophagogastric cancer patients in the UK: A single-centre experience

Background Covid-19 has had a devastating global impact and resulted in over 4.4 million directly attributed deaths. The UK entered lockdown in March 2020, redistributing its medical workforce and resources. Early estimations suggested at least 4700 extra cancer deaths at 5 years if there was a 3-month delay to surgery. Delays to diagnosis and treatment for osophagogastric (OG) cancers can be particularly detrimental to survival. The aim of this study is to assess the impact of Covid-19 on new cancer referrals to a centralised UK OG cancer centre, including presentation, decision making and treatment. Methods Patients with OG cancer referred to a tertiary, high-volume centre between March 2019 and March 2021 were reviewed. Patients were stratified into Pre-covid (March 2019-March 2020) and Covid (March 2020-2021) cohorts. Number of new referrals, clinical stage, treatment decision, and time to treatment were compared for gastric adenocarcinoma (GA), oesophagogastric-junction adenocarcinoma (OGJA), oesophageal adenocarcinoma (OA) and oesophageal SCC (OSCC). Results There was an 11% reduction in new cancer referrals (485 vs 431). GA, OGJA and OA did not have significant change in treatment intent, although there was a significant increase in the decision for definitive non-surgical treatment of OA (P = 0.046). GA and OA patients had a small, but significant increase in mean clinical stage at presentation (P < 0.05). There was no increase in time to treatment for GA, OGJA and OA. A significantly higher proportion of OSCC patients were given curative intent treatment in the Covid-19 cohort (P = 0.0006) however, this was accompanied with an increased time to treatment commencement (35.8 days vs 27.9 days P = 0.0198). Conclusions This high-volume centre has seen a reduction in new cancer referrals since the first UK lockdown. This was associated with a small, but significant, increase in clinical stage of GA and OA at presentation. This may represent an early indication of excess oesophagogastric cancer deaths due to the impact of Covid-19. This data also confirms initial results showing that oncological decisions were not compromised, although Covid-19 remains a dynamic challenge.

P-OGC60 Predicting the risk of venous thromboembolism during neoadjuvant therapy for oesophagogastric cancer

Background Locally advanced oesophageal cancer is usually treated with neoadjuvant treatment (NAT) followed by surgery. Venous thromboembolism (VTE) is a recognised complication in these patients. Those who develop VTE may have an inferior vena cava filter placed prior to surgery to reduce the risk of further complications. This study aimed to identify specific risks for VTE during (NAT) for oesophagogastric cancer (OGC) and whether this increases postoperative morbidity. Methods Patients undergoing NAT for OGC followed by surgery at a single high-volume centre between January 2015 and June 2020 were identified from a prospectively maintained database. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors for the development of VTE as well as the association between diagnosis of VTE and morbidity. Results The incidence of VTE in this cohort was 6.7% (27/406). Independent risk factors for developing VTE in multivariable analysis were BMI – OR 1.093 (p = 0.045) and age – OR 1.067 (p = 0.019). Type of chemo(radio)therapy regimen used, pT, pN stage, previous history of ischaemic heart disease or being an active smoker at diagnosis was not associated with VTE occurrence. Diagnosis of VTE during neoadjuvant treatment was not associated with a higher risk of developing a serious postoperative complication (Clavien-Dindo grade III and above) (p = 0.699). Conclusions Patients with a raised BMI or older age are at higher risk of developing VTE during NAT for OGC. These patients must be appropriately counseled on the higher risk of VTE prior to commencing NAT. However, the development of a VTE does not appear to confer any additional post-operative complication risk.

P-OGC43 Morbidity and unplanned hospital attendance among patients with oesophagogastric cancer treated with home enteral nutrition

Background Nutritional optimisation is an essential component of prehabilitation and enhanced recovery for patients with oesophageal and gastric cancer, but may be associated with increased burden of inpatient care. The aim of this study was to determine risk factors associated with complications and unplanned hospital attendance among patients treated with home enteral nutrition. Methods Consecutive patients with oesophageal or gastric cancer commencing home enteral nutrition from March 2020-June 2021 were prospectively studied. The primary outcome measure was the incidence of complications associated with home enteral feeding requiring unplanned hospital attendance. Univariable and multivariable linear and logistic regression were used to determine factors independently associated with enteral feeding associated morbidity and healthcare utilisation. Results 70 patients were studied (27% pre neoadjuvant therapy, 63% postoperative; 19% gastrostomy, 81% jejunostomy). Tube complications requiring unplanned hospital attendance occurred in 33% of patients (25% gastrostomy, 38% jejunostomy, P = 0.405), most commonly dislodgement (15%), fixation problem (13%), and blockage (6%). Small bowel obstruction was rare (1.4%). Inpatient length of stay (LOS) following feeding tube placement and training was 5.1±2.4 days (gastrostomy: 5.5±2.7, jejunostomy: 4.4±1.9 days, P = 0.074). 17 unplanned hospital visits among nine patients (13.0%) occurred with a cumulative LOS of 71 inpatient days. On multivariable analysis patients undergoing neoadjuvant therapy were at the greatest risk of overall enteral feeding tube morbidity (OR19.34 [3.29–113.56], P = 0.001), dislodgement (OR19.09 [2.35-155.11], P = 0.006) and unplanned hospital attendance (P < 0.001). Older patients were at increased risk of tube dislodgement (OR1.14 [1.02–1.28], P=0.024) and unplanned hospital attendance (P = 0.034). Conclusions Unplanned hospital attendance is common among patients undergoing supplemental home enteral nutrition during treatment for oesophagogastric cancer. Fixation problems and dislodgement account for the majority of presentations, and are more common among older patients and those undergoing neoadjuvant therapy. Pragmatic strategies to optimise tube fixation and minimise the need for unplanned hospital visits among patients receiving home enteral nutrition are urgently needed.

P-OGC45 Could lymphatic, vascular or perineural invasion status improve clinical staging prior to oesophagectomy?

Background Unimodal treatment of oesophagogastric cancer (OGC) with surgery only is currently reserved for patients with early disease. Presence of vascular (VI), perineural (PNI) or lymphatic vessel invasion (LI) in pathological samples have been shown to be negative prognostic indicators of survival. These factors have been found to be associated with more advanced disease. Staging of OGC has limitations and in neoadjuvant naive populations it has been shown to be imperfect. It is unknown whether VI, PNI or LI could play any role during the staging process. Methods Patients with early disease (cT2 or less and cN0) who underwent unimodal treatment of their oesophageal or junctional cancer with oesophagectomy between 2010 and 2019 in a single centre were included in this study. Therelationship between presence of LI, VI and PNI on pathological samples with incorrect staging/upstaging indicating locally advanced disease (defined as pT3+ or pN+) was studied using logistic regression model. Results There were 128 patients included. 26 patients (20%) were upstaged to pT3+ or pN+. LI, VI and PNI were present in 18%, 11% and 8% respectively. The presence of LI and clinical T stage were independently predictive of incorrect staging/upstaging in multivariable logistic regression analysis. LI (OR 12.5 95%CI 3.7-42.8, p < 0.001) and cT2 (OR 5.9 95%CI 1.5-23.2, p = 0.01). Conclusions These results indicate that the presence of LI from pathological samples is a strong independent prognostic factor of incorrect staging which would normally favour neoadjuvant treatment. The presence of LI suggests aggressive disease. Further studies should concentrate on the possibility of obtaining LI status from preoperative biopsies or endoscopic mucosal resection samples. This staging information could play an important role in deciding whether neoadjuvant therapy is indicated in patients staged as early disease.

P-OGC49 Reporting on Patient and Public Involvement in Oesophago-gastric Research Trials using the GRIPP 2 checklist

Background There is increasing evidence on the value of PPI reporting (patient public involvement) in all research. GRIPP2 (Guidance for Reporting Involvement of Patients and the Public) is the first international guidance for reporting of patient and public involvement in health and social care research. Associations with improved relevance and applicability may reduce research waste and target research funds more appropriately. The aim of this study was to review the reporting of PPI amongst all oesophago-gastric clinical trials undertaken between 2015 and 2021. Methods An electronic search in databases Medline, Embase and the Cochrane Library was conducted to identify all clinical trials pertaining to oesophagogastric cancer from 2015 to 2021(with the exception of reviews, case reports and conference abstracts). Articles were scanned by two authors to identify if reporting of PPI had taken place. Results A total of 334 studies were found, of which 285 met the inclusion and exclusion criteria.Only 4 studies had reported on PPI. Two of which reported positive involvement and two reported negatively. None of the studies reported using the GRIPP 2 checklist and when reported by this study, none achieved all points on the GRIPP2 SF checklist. An analysis on the extent of PPI involvement in these studies was carried out. Conclusions PPI is poorly reported across oesophago-gastric research trials.

Laparoscopic vs. open feeding jejunostomy insertion in oesophagogastric cancer

Background Jejunal feeding is an invaluable method by which to improve the nutritional status of patients undergoing neoadjuvant and surgical treatment of oesophageal malignancies. However, the insertion of a feeding jejunostomy can cause significant postoperative morbidity. The aim of this study is to compare the outcomes of patients undergoing placement of feeding jejunostomy by conventional laparotomy with an alternative laparoscopic approach. Methods A retrospective review of data prospectively collected at the Oxford Oesophagogastric Centre between August 2017 and July 2019 was performed including consecutive patients undergoing feeding jejunostomy insertion. Results In the study period, 157 patients underwent jejunostomy insertion in the context of oesophageal cancer therapy, 126 (80%) by open technique and 31 (20%) laparoscopic. Pre-operative demographic and nutritional characteristics were broadly similar between groups. In the early postoperative period jejunostomy-associated complications were noted in 54 cases (34.4%) and were significantly more common among those undergoing open as compared with laparoscopic insertion (38.1% vs. 19.3%, P = 0.049). Furthermore, major complications were more common among those undergoing open insertion, whether as a stand-alone or at the time of staging laparoscopy (n = 11/71), as compared with insertion at the time of oesophagectomy (n = 3/86, P = 0.011). Conclusions This report represents the largest to our knowledge single-centre comparison of open vs. laparoscopic jejunostomy insertion in patients undergoing oesophagectomy in the treatment of gastroesophageal malignancy. We conclude that the laparoscopic jejunostomy insertion technique described represents a safe and effective approach to enteral access which may offer superior outcomes to conventional open procedures.

EP.TH.359Improved Oesophagogastric Cancer Outcomes in Rural Patients

Introduction Despite advances in medical therapies and surgical techniques, oesophagogastric cancer survival remains low. Poorer cancer outcomes and survival for rural dwellers is well documented worldwide and has been an area of focus in Scotland since 2007, with changes to suspected cancer referral guidelines and a government report on delivering remote and rural healthcare. Methods A prospective, single-centre observation study was conducted utilising data from oesophago-gastric cancer MDT referrals and outcomes from January 2013 to December 2019. The Scottish Index of Multiple Deprivation 2020 tool provided a rurality code based on patient postcode at time of referral. Survival outcomes for urban and rural patients were compared across demographic factors, disease factors and stage at presentation. Results 1046 patients were included in this study. The median age of presentation for urban and rural patients was 73.7 and 72.4 respectively. There was no significant difference between oesophageal versus gastric cancer presentations nor was there any difference between T, N or M stage at presentation between the groups. No difference was identified between those commenced on a radical therapy with other treatment plans. On Kaplan-Meier analysis there was a difference in survival between the groups favouring rural dwellers (p = 0.012). Discussion The difference in survival demonstrated here between urban and rural groups is not easily explained but may represent improvements to rural access to healthcare delivered as a result of policy change. This is an interesting finding and this study should be expanded to include performance status at time of referral.