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Summary Large hiatus hernias with a significant paraesophageal component (types II–IV) have a range of insidious symptoms. Management of symptomatic hernias includes conservative treatment or surgery. Currently, there is no paraesophageal hernia disease-specific symptom questionnaire. As a result, many clinicians rely on the health-related quality of life questionnaires designed for gastro-esophageal reflux disease (GORD) to assess patients with hiatal hernias pre- and postoperatively. In view of this, a paraesophageal hernia symptom tool (POST) was designed. This POST questionnaire now requires validation and assessment of clinical utility. Twenty-one international sites will recruit patients with paraesophageal hernias to complete a series of questionnaires over a five-year period. There will be two cohorts of patients—patients with paraesophageal hernias undergoing surgery and patients managed conservatively. Patients are required to complete a validated GORD-HRQL, POST questionnaire, and satisfaction questionnaire preoperatively. Surgical cohorts will also complete questionnaires postoperatively at 4–6 weeks, 6 months, 12 months, and then annually for a total of 5 years. Conservatively managed patients will repeat questionnaires at 1 year. The first set of results will be released after 1 year with complete data published after a 5-year follow-up. The main results of the study will be patient’s acceptance of the POST tool, clinical utility of the tool, assessment of the threshold for surgery, and patient symptom response to surgery. The study will validate the POST questionnaire and identify the relevance of the questionnaire in routine management of paraesophageal hernias.

In 2015 the Esophagectomy Complications Consensus Group (ECCG) reported consensus definitions for complications after oesophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition-set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomised studies reporting complication frequencies after oesophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Study quality was assessed using the Newcastle-Ottawa score. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the ten most common complications was reduced in ECCG adopting studies vs non-adopting studies (p = 0.036) (see Figure 1). Among ECCG studies, the frequencies of post-operative pneumothorax, re-intubation and pulmonary emboli were reduced in 2020–2021, compared to 2015–2019 (p = 0.006, 0.034 and 0.037 respectively). There was no difference in the quality of ECCG adopting studies and non-adopting studies. The ECCG definition-set has reduced variation in oesophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020–2021, compared with 2015–2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky tumors, but there are concerns that this approach is associated with significant morbidity. The aim of the current study was to evaluate short-term and oncological outcomes of left thoracoabdominal esophagectomy compared to minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction. Methods Prospectively entered esophagectomy databases from three high volume centers were reviewed for patients undergoing LTE or MIE 2012–2018. Patient demographics, tumour characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared. In total 844 patients were included in the study, LTE was applied in 654 (77.5%) patients, and MIE in 190 (22.5%) patients. Results LTE patients had more neoadjuvant treatment (LTE = 74.5%, MIE = 64.9%, P = 0.027). There was no difference in overall postoperative complications (LTE = 61.9%, MIE = 64.6%, P = 0.517), severe complications (Clavien Dindo >IIIa (LTE = 26.6%, MIE 26.5%, P = 0.982), pneumonia (LTE = 29.8%, MIE = 26.3%, P = 0.349), anastomotic leak (LTE = 7.7%, MIE = 9.9%, P = 0.348), or in-hospital mortality (LTE = 1.5%, MIE = 2.1%, P = 0.584). Median length of stay was 11 days after LTE vs. 8 days after MIE (P Conclusion LTE was used for tumors with greater lymph node burden in patients that were more likely to have received neoadjuvant treatment compared to MIE. MIE was associated with significantly shorter length of hospital stay, however postoperative morbidity and Clavien-Dindo scores were equal to that of MIE in this cohort.

Aim Long-term functional outcomes and the associations to health-related quality of life (HRQOL) after esophagectomy is largely unknown. LASER is a multi-center European study aimed to identify the most prevalent symptoms, and those with the greatest impact upon HRQOL among patients surviving more than one-year after esophagectomy for cancer, and to develop a clinically relevant symptom-based tool to measure HRQOL. Background & Methods Between 2010 and 2016, patients from 20 European Centers who underwent esophagectomy for esophageal cancer, and were disease-free at least one year postoperatively were invited to complete the LASER questionnaire, EORTC-QLQ30 and OG25. Specific symptom questionnaire items that were associated with a poor HRQOL as identified by EORTC-QLQC30 and OG25 were identified by multivariable linear and logistic regression analysis and combined to form a tool, which was tested using receiver operating characteristics curve analysis. Results A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had had symptoms associated with their esophagectomy and 52.4% of patients had sought medical treatment for their symptoms. Ongoing weight loss was reported by 10.4% of patients while 32.4% were struggling to maintain their body weight, and 18.8% of patients required supplemental oral nutrition. Only 13.8% of patients had returned to work with the same activities as before. Three LASER symptoms in multivariate analysis were correlated with poor HRQOL; pain on scars on chest (Odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81±0.02 and 0.82±0.09 respectively. Conclusions Two-thirds of patients experience symptoms related to their esophagectomy more than one year after surgery. The three key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased long-term term support.

The ability to predict complications following esophagectomy/extended total gastrectomy would be of great clinical value. A recent study demonstrated significant correlations between anastomotic leak (AL) and numerical values of C-reactive protein (CRP), white cell count (WCC) and albumin measured on postoperative day (POD) 4. A predictive model comprising all three (NUn score >10) was found to be highly sensitive and discriminant in predicting AL and complications. We attempted a retrospective validation in our center. Data were collected on all resections performed during a 5-year period (April 2008-2013) using prospectively maintained databases. Our biochemistry laboratory uses a maximum CRP value (156 mg/L), unlike that of the original study; otherwise all variables and outcome measures were comparable. Analysis was performed for all patients with complete blood results on POD4. Three hundred twenty-six patients underwent resection, of which 248 had POD4 bloods. There were 21 AL overall (6.44%); 16 among those with complete POD4 blood results (6.45%). There were 8 (2.45%) in-hospital deaths; 7 (2.82%) in those with POD4 results. No parameters were associated with AL or complication severity on univariate analysis. WCC was associated with AL in multivariate binary logistic regression with albumin and CRP (OR 1.23 [95% CI 1.03-1.47]; P = 0.021). When a binary variable of CRP ≥ 156 mg/L was used rather than an absolute value, no factors were significant. Mean NUn was 8.30 for AL, compared with 8.40 for non-AL (P = 0.710 independent t-test). NUn > 10 predicted 0 of 16 leaks (sensitivity 0.00%, specificity 94.4%, receiver operator curve [ROC] area under the curve [AUC] 0.485; P = 0.843). NUn > 7.65 was 93% sensitive and 21.6% specific. ROC for WCC alone was comparable with NUn (AUC 0.641 [0.504-0.779]; P = 0.059; WCC > 6.89 93.8% sensitive, 20.7% specific; WCC > 15 6.3% sensitive and 97% specific). There were no associations between any parameters and other complications. In a comparable cohort with the original study, we demonstrated a similar multivariate association between WCC alone on POD4 and subsequent demonstration of AL, but not albumin or CRP (measured up to 156 mg/L). The NUn score overall (calculated with this caveat) and a threshold of 10 was not found to have clinical utility in predicting AL or complications.

Enhanced recovery after surgery (ERAS) pathways aim to accelerate functional return and discharge from hospital. They have proven effective in many forms of surgery, most notably colorectal. However, experience in esophagectomy has been limited. A recent study reported significant reductions in pulmonary complications, mortality, and length of stay following the introduction of an ERAS protocol alone, without the introduction of any clinical changes. We instituted a similar change 16 months ago, introducing a protocol to provide a formal framework, for our existing postoperative care. This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change. Data were collected from prospectively maintained secure web-based multidisciplinary databases. Complication severity was classified using the Clavien-Dindo scale. Operative mortality was defined as death within 30 days of surgery, or at any point during the same hospital admission. Lower respiratory tract infection was defined as clinical evidence of infection, with or without radiological signs. Respiratory complications included lower respiratory tract infection, pleural effusion (irrespective of drainage), pulmonary collapse, and pneumothorax. Statistical analysis was performed using SPSS v21. One hundred thirty-two patients underwent esophagectomy (55 protocol group; 77 before). All were performed open. There were no differences between the two groups in terms of age, gender, operation, use of neoadjuvant therapy, cell type, stage, tumor site, or American Society of Anesthesiologists grade. Median length of stay was 14.0 days (protocol) compared with 12.0 before (interquartile range 9-19 and 9.5-15.5, respectively; P = 0.073, Mann-Whitney U-test). Readmission within 30 days of discharge occurred in five (9.26%) and six (8.19%; P = 1.000, Fisher's exact test). There were four in-hospital deaths (3.03%): one (1.82%) and three (3.90%), respectively (P = 0.641). There were no differences in the severity of complications (P = non-significant; Pearson's chi-squared). There were no differences in the type of complications occurring in either group. The protocol was completed successfully by 26 (47.3%). No baseline factors were predictive of this. In contrast to previous studies, we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol. Consequently, improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care. Consequently, we would recommend that centers introducing new (or reviewing existing) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such standardized pathways.

Background In an era of increased utilisation of multimodality treatment for oesophageal adenocarcinoma the role of radical lymphadenectomy remains controversial. The objectives of this population-based cohort study were to evaluate the influence of lymph node harvest upon short- and long-term mortality following oesophagectomy for oesophageal adenocarcinoma, with subset analysis of patients receiving neoadjuvant therapy. Methods The UK National Oesophago-Gastric Cancer Audit (NOGCA) was used to identify suitable patients operated on between 1st April 2012 and 31st March 2016. Logistic regression of confounders was used to generate predicted mortality probabilities for utilisation in Risk-Adjusted Cumulative Sum (RA-CUSUM) analysis to identify the lymph node harvest change-points associated with changes in one-, two- and three-year mortality. Results Within the three-year study period, 3883 patients were included of these 2192 patients (56%) received neoadjuvant chemotherapy. For all patients there were non-significant change-points in 1-, 2-, and 3-year mortality at 19, 27 and 19 lymph nodes respectively. For patients receiving neoadjuvant therapy change-point analysis did show statistically significant reductions in 2-year mortality (44.9% before to 39.2% after 19 lymph nodes; P = 0.017) and 3-year mortality (55.0% before to 47.4% after 20 lymph nodes; P = 0.035). 30-day and 90-day mortality and anastomotic leak were not significantly by lymph node harvest of greater than 19 lymph nodes. Conclusion The results of this national population-based cohort study suggest that at least 20 lymph nodes should be harvested during oesophagectomy given the prognostic importance in oesophageal adenocarcinoma, and the benefits to improve pathological staging of the patient and appropriately allocate adjuvant therapy. Disclosure All authors have declared no conflicts of interest.

SUMMARY The left thoracoabdominal approach to esophagectomy is not widely performed, despite offering excellent exposure to tumors of the esophagogastric junction. Criticisms of the approach have focused on historically high rates of mortality, complications, and positive resection margins. Our aim was to determine whether left thoracoabdominal esophagectomy could combine a radical oncological resection with acceptably low mortality and morbidity. A retrospective cohort study of all left thoracoabdominal esophagectomies was performed at a single specialist center over an 11-year period. Primary outcomes were in-hospital mortality, complications, resection margin involvement, and lymph node yield; secondary outcomes were 1-year and 5-year survival. Two hundred eleven esophagectomies were performed. In-hospital mortality was 5.7% (12/211). One hundred one subjects (47.9%) had an uncomplicated recovery; 110 subjects (52.1%) developed at least one complication. There were 15 clinically significant anastomotic leaks (7.1%). Twenty-four subjects (11.4%) required emergency reoperation, the most common indication being anastomotic leakage. Complete tumor excision (R0 resection) was achieved in 151 of 211 cases (71.6%); median lymph node yield was 24. One-year and 5-year survival rates were 70% (147/211) and 21% (24/116), respectively. Left thoracoabdominal esophagectomy can combine a radical oncological resection with acceptably low mortality and morbidity.