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Background Upper gastrointestinal cancers are aggressive malignancies with poor prognosis, even following multimodality therapy. As such, they require timely and accurate diagnostic and surveillance strategies; however, such radiological workflows necessitate considerable expertise and resource to maintain. In order to lessen the workload upon already stretched health systems, there has been increasing focus on the development and use of artificial intelligence (AI)-centred diagnostic systems. This systematic review summarizes the clinical applicability and diagnostic performance of AI-centred systems in the diagnosis and surveillance of esophagogastric cancers. Methods A systematic review was performed using the MEDLINE, EMBASE, Cochrane Review, and Scopus databases. Articles on the use of AI and radiomics for the diagnosis and surveillance of patients with esophageal cancer were evaluated, and quality assessment of studies was performed using the QUADAS-2 tool. A meta-analysis was performed to assess the diagnostic accuracy of sequencing methodologies. Results Thirty-six studies that described the use of AI were included in the qualitative synthesis and six studies involving 1352 patients were included in the quantitative analysis. Of these six studies, four studies assessed the utility of AI in gastric cancer diagnosis, one study assessed its utility for diagnosing esophageal cancer, and one study assessed its utility for surveillance. The pooled sensitivity and specificity were 73.4% (64.6–80.7) and 89.7% (82.7–94.1), respectively. Conclusions AI systems have shown promise in diagnosing and monitoring esophageal and gastric cancer, particularly when combined with existing diagnostic methods. Further work is needed to further develop systems of greater accuracy and greater consideration of the clinical workflows that they aim to integrate within.

Background No well validated and contemporaneous tools for personalized prognostication of gastric adenocarcinoma exist. This study aimed to derive and validate a prognostic model for overall survival after surgery for gastric adenocarcinoma using a large national dataset. Methods National audit data from England and Wales were used to identify patients who underwent a potentially curative gastrectomy for adenocarcinoma of the stomach. A total of 2931 patients were included and 29 clinical and pathological variables were considered for their impact on survival. A non-linear random survival forest methodology was then trained and validated internally using bootstrapping with calibration and discrimination (time-dependent area under the receiver operator curve (tAUC)) assessed. Results The median survival of the cohort was 69 months, with a 5-year survival of 53.2 per cent. Ten variables were found to influence survival significantly and were included in the final model, with the most important being lymph node positivity, pT stage and achieving an R0 resection. Patient characteristics including ASA grade and age were also influential. On validation the model achieved excellent performance with a 5-year tAUC of 0.80 (95 per cent c.i. 0.78 to 0.82) and good agreement between observed and predicted survival probabilities. A wide spread of predictions for 3-year (14.8–98.3 (i.q.r. 43.2–84.4) per cent) and 5-year (9.4–96.1 (i.q.r. 31.7–73.8) per cent) survival were seen. Conclusions A prognostic model for survival after a potentially curative resection for gastric adenocarcinoma was derived and exhibited excellent discrimination and calibration of predictions.

Background Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life. Methods This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models. Results Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms. Conclusion A long-term symptom burden is common after oesophageal cancer surgery.

Aim This is the first randomised study to evaluate toxicity and survival outcomes of two neoadjuvant chemoradiotherapy (CRT) regimens for patients with localised oesophageal adenocarcinoma (OAC) or gastro-oesophageal junction (GOJ) adenocarcinoma. The initial results showed comparable toxicity between regimens and pathological complete response (pCR) rate favouring CarPacRT. Herein, we report survival, progression patterns, and long-term toxicity after a median follow-up of 40.7 months. Methods NeoSCOPE was an open-label, UK multicentre, randomised, phase II trial. Eighty-five patients with resectable OAC or GOJ adenocarcinoma, ≥cT3 and/or ≥cN1 (TNM v7), suitable for neoadjuvant CRT, were recruited between October 2013 and February 2015. Patients were randomised to OxCapRT (oxaliplatin 85 mg/m2 on Days 1, 15, and 29; capecitabine 625 mg/m2 orally twice daily on days of radiotherapy [RT]) or CarPacRT (carboplatin AUC2; paclitaxel 50 mg/m2 on Days 1, 8, 15, 22, and 29). RT dose was 45 Gy/25 fractions/5 weeks. Both arms received induction chemotherapy (two cycles oxaliplatin 130 mg/m2 on Day 1, capecitabine 625 mg/m2 orally twice daily on Days 1–21) before CRT. Surgery was performed 6–8 weeks after CRT. The primary end-point was pCR. Secondary end-points were toxicity, progression-free survival (PFS), overall survival (OS), and patterns of progression. Results Eighty-five patients were recruited from 17 UK centres. The median OS was 41.7 months (95% confidence interval [CI] 19.6 to not reached) in the OxCapRT arm and was not reached in the CarPacRT arm (multivariable hazard ratio [HR] = 0.48, 95% CIs: 0.24–0.95, P = 0.035). The median PFS was 32.6 months (95% CIs: 17.1 to not reached) in the OxCapRT arm and was not reached in the CarPacRT arm (multivariable HR = 0.54, 95% CIs: 0.29–1.01, P = 0.053). In both arms, the distant progression was twice as common as locoregional progression. Conclusions OS and PFS favoured neoadjuvant CarPacRT over OxCapRT. Distant was more common than locoregional progression; therefore, priority should be given to optimising the systemic treatment component. Clinical trial information EudraCT Number: 2012-000640-10; ClinicalTrials.gov: NCT01843829., Highlights • Randomised study of neoadjuvant chemoradiotherapy for oesophageal adenocarcinoma. • The median overall survival was significantly better with CarPacRT. • Across both arms, the distant was more common than locoregional progression.

Objective To identify the most prevalent symptoms and those with greatest impact upon health-related quality of life (HRQOL) among esophageal cancer survivors. Background Long-term symptom burden after esophagectomy, and associations with HRQOL, are poorly understood. Patients and methods Between 2010 and 2016, patients from 20 European Centers who underwent esophageal cancer surgery, and were disease-free at least 1 year postoperatively were asked to complete LASER, EORTC-QLQ-C30, and QLQ-OG25 questionnaires. Specific symptom questionnaire items that were associated with poor HRQOL as identified by EORTC QLQ-C30 and QLQ-OG25 were identified by multivariable regression analysis and combined to form a tool. 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 symptoms associated with their esophagectomy. Ongoing weight loss was reported by 10.4% of patients, and only 13.8% returned to work with the same activities.Three LASER symptoms were correlated with poor HRQOL on multivariable analysis; 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. Conclusion Two-thirds of patients experience significant symptoms more than 1 year after surgery. The 3 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 support.

Introduction\ud \ud Patients with cancer who develop small bowel obstruction are at high risk of malnutrition and morbidity following compromise of gastrointestinal tract continuity. This study aimed to characterise current management and outcomes following malignant small bowel obstruction.\ud \ud \ud \ud Methods\ud \ud A prospective, multicentre cohort study of patients with small bowel obstruction who presented to UK hospitals between 16th January and 13th March 2017. Patients who presented with small bowel obstruction due to primary tumours of the intestine (excluding left-sided colonic tumours) or disseminated intra-abdominal malignancy were included. Outcomes included 30-day mortality and in-hospital complications. Cox-proportional hazards models were used to generate adjusted effects estimates, which are presented as hazard ratios (HR) alongside the corresponding 95% confidence interval (95% CI). The threshold for statistical significance was set at the level of P ≤ 0.05 a-priori.\ud \ud \ud \ud Results\ud \ud 205 patients with malignant small bowel obstruction presented to emergency surgery services during the study period. Of these patients, 50 had obstruction due to right sided colon cancer, 143 due to disseminated intraabdominal malignancy, 10 had primary tumours of the small bowel and 2 patients had gastrointestinal stromal tumours. In total 100 out of 205 patients underwent a surgical intervention for obstruction. 30-day in-hospital mortality rate was 11.3% for those with primary tumours and 19.6% for those with disseminated malignancy. Severe risk of malnutrition was an independent predictor for poor mortality in this cohort (adjusted HR 16.18, 95% CI 1.86 to 140.84, p = 0.012). Patients with right-sided colon cancer had high rates of morbidity.\ud \ud \ud \ud Conclusions\ud \ud Mortality rates were high in patients with disseminated malignancy and in those with right sided colon cancer. Further research should identify optimal management strategy to reduce morbidity for these patient groups.

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.

Background: Over 1500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation.Material and methods: An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data.Results: Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions.Conclusions: Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

Summary Background Paraesophageal hernias (PEH) present with a range of symptoms affecting physical and mental health. This systematic review aims to assess the quality of reporting standards for patients with PEH, identify the most frequently used quality of life (QOL) and symptom severity assessment tools in PEH and to ascertain additional symptoms reported by these patients not captured by these tools. Methods A systematic literature review according to PRISMA protocols was carried out following a literature search of MEDLINE, Embase and Cochrane databases for studies published between January 1960 and May 2020. Published abstracts from conference proceedings were included. Data on QOL tools used and reported symptoms were extracted. Results This review included 220 studies reporting on 28 353 patients. A total of 46 different QOL and symptom severity tools were used across all studies, and 89 different symptoms were reported. The most frequently utilized QOL tool was the Gastro-Esophageal Reflux Disease-Health related quality of life questionnaire symptom severity instrument (47.7%), 57.2% of studies utilized more than 2 QOL tools and ‘dysphagia’ was the most frequently reported symptom, in 55.0% of studies. Notably, respiratory and cardiovascular symptoms, although less common than GI symptoms, were reported and included ‘dyspnea’ reported in 35 studies (15.9%). Conclusions There lacks a QOL assessment tool that captures the range of symptoms associated with PEH. Reporting standards for this cohort must be improved to compare patient outcomes before and after surgery. Further investigations must seek to develop a PEH specific tool, that encompasses the relative importance of symptoms when considering surgical intervention and assessing symptomatic improvement following surgery.

Esophago-gastric malignancies are associated with a high recurrence rate; yet there is a lack of evidence to inform guidelines for the standardization and structure of postoperative surveillance after curatively intended treatment. This study aimed to capture the variation in postoperative surveillance strategies across the UK and Ireland, and enquire the opinions and beliefs around surveillance from practicing clinicians. A web-based survey consisting of 40 questions was sent to surgeons or allied health professionals performing or involved in surgical care for esophago-gastric cancers at high-volume centers in the UK. Respondents from each center completed the survey on what best represented their center. The first section of the survey evaluated the timing and components of follow-ups, and their variation between centers. The second section evaluated respondents perspective on how surveillance can be structured. Thirty-five respondents from 27 centers consisting 28 consultants, 6 senior trainees and 1 specialist nurse had completed the questionnaire; 45.7% of responders arranged clinical follow-up at 2–4 weeks. Twenty responders had a specific postoperative surveillance protocol for their patients. Of these, 31.4% had a standardized protocol for all patients, while 25.7% tailored it to patient needs. Patient preference, comorbidities and chance of recurrence were considered as major factors for necessitating more intense surveillance than currently practiced. There is a significant variation in how patients are monitored after surgery between centers in the UK. Randomized controlled trials are necessary to link surveillance strategies to both survival outcomes and quality of life of patients and to evaluate the prognostic value of different postoperative surveillance strategies.

Our paper highlights the use of artificial intelligence (AI) in oesophageal and gastric malignancies with acceptable levels of accuracy for both diagnostic and surveillance purposes. Here, we comment on the past, present and future work necessary for incorporating AI into the clinical framework and practice.

Introduction For patients with oesophageal cancer, producing accurate prediction models for survival after oesophagectomy has proved challenging. We investigated whether Random Survival Forests (RSF), a novel machine learning method, could produce an accurate prognostic model for overall survival after oesophagectomy. Method The study used data from the National Oesophago-Gastric Cancer Audit and included patients diagnosed with oesophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales and who underwent a curative oesophagectomy with adequate lymphadenectomy (15 LN) and survived to discharge (n=6198). Missing data was handled using multiple imputation and the data was split into training and validation cohorts. 13 variables were selected for inclusion using Random Forest variable importance and used to train the final model. The same variables were used to develop a traditional Cox regression model. Result Median survival was 53 months in both cohorts. The final RSF model had good discrimination in the validation cohort with a C-index of 0.757(0.755-0.759), exceeding the Cox model; 0.748(0.746-0.750). At 3 years post-surgery, overall survival was 56.2%. The RSF yielded a mean predicted survival of 55.8%(IQR 29.5%-81.7%) compared to 55.4%(40.0%-77.7%) for the Cox model. The most important variables were lymph node involvement and pT/ypT stage, however other variables including neoadjuvant treatment completion and surgical complications were also found to be important. Conculsion A Random Forest survival model provided better performance in predicting survival after curative oesophagectomy. This will allow more personalised predictions to be delivered clinicians and patients. Take-home message Random Forest survival models can accurately predict post-operative prognosis after oesophagectomy.

OBJECTIVE: To develop a predictive model for overall survival after esophagectomy using pre/postoperative clinical data and machine learning. SUMMARY BACKGROUND DATA: For patients with esophageal cancer, accurately predicting long-term survival after esophagectomy is challenging. This study investigated survival prediction after esophagectomy using a Random Survival Forest (RSF) model derived from routine data from a large, well curated, national dataset. METHODS: Patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales who underwent an esophagectomy were included. Prediction models for overall survival were developed using the RSF method and Cox regression from 41 patient and disease characteristics. Calibration and discrimination (time dependent AUC) were validated internally using bootstrap resampling. RESULTS: The study analysed 6399 patients, with 2625 deaths during follow-up. Median follow-up was 41 months. Overall survival was 47.1% at 5 years. The final RSF model included 14 variables and had excellent discrimination with a 5-year tAUC of 83.9% (95%CI 82.6-84.9%), compared to 82.3% (95%CI 81.1-83.3%) for the Cox model. The most important variables were lymph node involvement, pT stage, CRM involvement (tumour at

Background Histopathological outcomes, such as lymph node yield and margin positivity, are used to benchmark and assess surgical centre quality, and are reported annually by the National Oesophago-Gastric Cancer Audit (NOGCA) in England and Wales. The variation in pathological specimen assessment and how this affects these outcomes is not known. Methods A survey of practice was circulated to all tertiary oesophagogastric cancer centres across England and Wales. Questions captured demographic data, and information on how specimens were prepared and analysed. National performance data were retrieved from the NOGCA. Survey results were compared for tertiles of lymph node yield, and circumferential and longitudinal margins. Results Survey responses were received from 32 of 37 units (86 per cent response rate), accounting for 93.1 per cent of the total oesophagectomy volume in England and Wales. Only 5 of 32 units met or exceeded current guidelines on specimen preparation according to the Royal College of Pathologists guidelines. There was wide variation in how centres defined positive (R1) margins, and how margins and lymph nodes were assessed. Centres with the highest nodal yield were more likely to use systematic fat blocking, and to re-examine specimens when the initial load was low. Systematic blocking of lesser curve fat resulted in significantly higher rates of patients with at least 15 lymph nodes examined (91.4 versus 86.5 per cent; P = 0.027). Conclusion Preparation and histopathological assessment of specimens varies significantly across institutions. This challenges the validity of currently used surgical quality metrics for oesophageal and other tumours.

Background Risk assessment is relevant to predict postoperative outcomes in patients with gastro‐oesophageal cancer. This cohort study aimed to assess body composition changes during neoadjuvant chemotherapy and investigate their association with postoperative complications. Methods Consecutive patients with gastro‐oesophageal cancer undergoing neoadjuvant chemotherapy and surgery with curative intent between 2016 and 2019 were identified from a specific database and included in the study. CT images before and after neoadjuvant chemotherapy were used to assess the skeletal muscle index, sarcopenia, and subcutaneous and visceral fat index. Results In a cohort of 199 patients, the mean skeletal muscle index decreased during neoadjuvant therapy (from 51·187 to 49·19 cm2/m2; P, Deconditioning during neoadjuvant chemotherapy is a possible parameter for predicting operative outcomes. This retrospective cohort study aimed to assess body composition changes in patients with gastro‐oesophageal cancer during neoadjuvant therapy and investigate their association with postoperative complications. Skeletal muscle index values decrease during neoadjuvant therapy, but this change is not associated with postoperative complications. Does not predict risk of complications

Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure. A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system. Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure. The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.

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.

Background and aims: Radical endoscopic excision of Barrett’s epithelium performing 4 – 6 endoscopic resections during the same endoscopic session results in complete Barrett’s eradication but has a high stricture rate (40 – 80 %). Therefore radiofrequency ablation is preferred after endoscopic mucosal resection (EMR) of visible nodules. We investigated the clinical outcome of non-radical, stepwise endoscopic mucosal resection with a maximum of two endoscopic resections per endoscopic session. Methods: We analysed our prospectively maintained database of patients undergoing esophageal EMR for early neoplasia in Barrett’s esophagus from 2009 to 2014. EMR was performed using a maximum of two band ligation mucosectomies per endoscopic session; thereafter, follow-up was 3-monthly and EMR was repeated as required for Barrett’s eradication. Results: In total, 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumor stages or were managed conservatively. The remaining 91 patients with high grade dysplasia (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months. Remission of dysplasia/neoplasia was achieved in 95.6 % after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s eradication in 36/91 patients (39.6 %) in a mean of four sessions; 40/91 patients (44.0 %) had a short circumferential Barrett’s segment (

OBJECTIVE: Utilizing a standardized dataset with specific definitions to prospectively collect international data to provide a benchmark for complications and outcomes associated with esophagectomy. SUMMARY OF BACKGROUND DATA: Outcome reporting in oncologic surgery has suffered from the lack of a standardized system for reporting operative results particularly complications. This is particularly the case for esophagectomy affecting the accuracy and relevance of international outcome assessments, clinical trial results, and quality improvement projects. METHODS: The Esophageal Complications Consensus Group (ECCG) involving 24 high-volume esophageal surgical centers in 14 countries developed a standardized platform for recording complications and quality measures associated with esophagectomy. Using a secure online database (ESODATA.org), ECCG centers prospectively recorded data on all resections according to the ECCG platform from these centers over a 2-year period. RESULTS: Between January 2015 and December 2016, 2704 resections were entered into the database. All demographic and follow-up data fields were 100% complete. The majority of operations were for cancer (95.6%) and typically located in the distal esophagus (56.2%). Some 1192 patients received neoadjuvant chemoradiation (46.1%) and 763 neoadjuvant chemotherapy (29.5%). Surgical approach involved open procedures in 52.1% and minimally invasive operations in 47.9%. Chest anastomoses were done most commonly (60.7%) and R0 resections were accomplished in 93.4% of patients. The overall incidence of complications was 59% with the most common individual complications being pneumonia (14.6%) and atrial dysrhythmia (14.5%). Anastomotic leak, conduit necrosis, chyle leaks, recurrent nerve injury occurred in 11.4%, 1.3%, 4.7%, and 4.2% of cases, respectively. Clavien-Dindo complications ≥ IIIb occurred in 17.2% of patients. Readmissions occurred in 11.2% of cases and 30- and 90-day mortality was 2.4% and 4.5%, respectively. CONCLUSION: Standardized methods provide contemporary international benchmarks for reporting outcomes after esophagectomy.

The objectives of this national study were to examine the short-term safety and long-term survival benefit associated with surgical resection of hepatic metastases from gastric cancer. Patients from the Hospital Episode Statistics database were classified by disease and treatment approach. Gastric cancer: 1. Without liver metastases treated by gastrectomy (GG). 2. With liver metastases treated by gastrectomy and hepatectomy (GGH). 3. With liver metastases treated by gastrectomy without hepatectomy (GGNH). 4. With liver metastases treated with no surgery (GNS). Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics. During the study period, 87,482 were patients diagnosed with gastric cancer, of whom 13,841 underwent partial or total gastrectomy. Of those who underwent gastrectomy, 336 had a diagnosis of liver metastases and 78 of these had a hepatectomy. Propensity-matched analysis showed no significant differences in 30- or 90-day mortality between the GGH and GG groups. The GGH group had significantly improved 1-year mortality (35.9 % vs. 50.0 %, p = 0.049) and 5-year mortality (61.5 % vs. 75.7 %, p = 0.031) compared to the GGNH group, and compared to the GNS group, the GCH group had 1-year mortality (35.9 % vs. 84.6 %, p

Dysphagia in people with advanced oesophageal cancer can be treated by oesophageal stents, external beam radiotherapy (EBRT) and intraluminal brachytherapy. Despite guidelines recommending brachytherapy for patients with a predicted life expectancy exceeding 3 months, its uptake in the UK has been limited. Here we examine the strength of the evidence supporting the use of brachytherapy compared with oesophageal stents and EBRT and possible reasons for its limited uptake. Trials and observational studies suggest brachytherapy alone confers a benefit to patients, but its impact is less immediate than oesophageal stents; the evidence on effectiveness and value-for-money is limited. Moreover, stronger evidence will probably be insufficient to increase uptake, due to the extra complexity of delivery compared with stents and EBRT and a lack of experience among specialists.

BACKGROUND: Oesophageal adenocarcinoma is the sixth most common cause of cancer death worldwide and Barrett's oesophagus is the biggest risk factor. We aimed to evaluate the efficacy of high-dose esomeprazole proton-pump inhibitor (PPI) and aspirin for improving outcomes in patients with Barrett's oesophagus.METHODS: The Aspirin and Esomeprazole Chemoprevention in Barrett's metaplasia Trial had a 2 × 2 factorial design and was done at 84 centres in the UK and one in Canada. Patients with Barrett's oesophagus of 1 cm or more were randomised 1:1:1:1 using a computer-generated schedule held in a central trials unit to receive high-dose (40 mg twice-daily) or low-dose (20 mg once-daily) PPI, with or without aspirin (300 mg per day in the UK, 325 mg per day in Canada) for at least 8 years, in an unblinded manner. Reporting pathologists were masked to treatment allocation. The primary composite endpoint was time to all-cause mortality, oesophageal adenocarcinoma, or high-grade dysplasia, which was analysed with accelerated failure time modelling adjusted for minimisation factors (age, Barrett's oesophagus length, intestinal metaplasia) in all patients in the intention-to-treat population. This trial is registered with EudraCT, number 2004-003836-77.FINDINGS: Between March 10, 2005, and March 1, 2009, 2557 patients were recruited. 705 patients were assigned to low-dose PPI and no aspirin, 704 to high-dose PPI and no aspirin, 571 to low-dose PPI and aspirin, and 577 to high-dose PPI and aspirin. Median follow-up and treatment duration was 8·9 years (IQR 8·2-9·8), and we collected 20 095 follow-up years and 99·9% of planned data. 313 primary events occurred. High-dose PPI (139 events in 1270 patients) was superior to low-dose PPI (174 events in 1265 patients; time ratio [TR] 1·27, 95% CI 1·01-1·58, p=0·038). Aspirin (127 events in 1138 patients) was not significantly better than no aspirin (154 events in 1142 patients; TR 1·24, 0·98-1·57, p=0·068). If patients using non-steroidal anti-inflammatory drugs were censored at the time of first use, aspirin was significantly better than no aspirin (TR 1·29, 1·01-1·66, p=0·043; n=2236). Combining high-dose PPI with aspirin had the strongest effect compared with low-dose PPI without aspirin (TR 1·59, 1·14-2·23, p=0·0068). The numbers needed to treat were 34 for PPI and 43 for aspirin. Only 28 (1%) participants reported study-treatment-related serious adverse events.INTERPRETATION: High-dose PPI and aspirin chemoprevention therapy, especially in combination, significantly and safely improved outcomes in patients with Barrett's oesophagus.FUNDING: Cancer Research UK, AstraZeneca, Wellcome Trust, and Health Technology Assessment.

Background Following CT, guidelines for staging oesophageal and gastro-oesophageal junction (GOJ) cancer recommend endoscopic ultrasonography (EUS), PET–CT and laparoscopy for T3–T4 GOJ tumours. These recommendations are based on generic utilities, but it is unclear whether the test risk outweighs the potential benefit for some patients. This study sought to quantify investigation risks, benefits and utilities, in order to develop pragmatic, personalized staging recommendations. Methods All patients with a histological diagnosis of oesophageal or GOJ cancer staged between May 2006 and July 2013 comprised a development set; those staged from July 2013 to July 2014 formed the prospective validation set. Probability thresholds of altering management were calculated and predictive factors identified. Algorithms and models (decision tree analysis, logistic regression, artificial neural networks) were validated internally and independently. Results Some 953 patients were staged following CT, by [18F]fluorodeoxyglucose PET–CT (918), EUS (798) and laparoscopy (458). Of these patients, 829 comprised the development set (800 PET–CT, 698 EUS, 397 laparoscopy) and 124 the validation set (118 PET–CT, 100 EUS, 61 laparoscopy). EUS utility in the 71·8 per cent of patients with T2–T4a disease on CT was minimal (0·4 per cent), its risk exceeding benefit. EUS was moderately accurate for pT1 N0 disease. A number of factors predicted metastases on PET–CT and laparoscopy, although none could inform an algorithm. PET–CT altered management in 23·0 per cent, and laparoscopy in 7·1 per cent, including those with T2 and distal oesophageal tumours. Conclusion Although EUS provided additional information on T and N category, its risk outweighed potential benefit in patients with T2–T4a disease on CT. Laparoscopy seemed justified for distal oesophageal tumours of T2 or greater.

Endoscopic mucosal resection (EMR) has become the standard treatment for early oesophageal neoplasia. The mucosal defect caused by EMR usually takes several weeks to heal. Despite guidelines on high-risk endoscopic procedures in patients on anticoagulation, evidence is lacking whether EMR is safe in such patients. We investigated the immediate and delayed bleeding risk in patients undergoing diagnostic or therapeutic oesophageal EMR comparing patients requiring warfarin anticoagulation with a control group. Warfarin was stopped 5 days before the planned EMR and restarted on the evening following the procedure. Patients with high-risk conditions, such as recent pulmonary thromboemboli, received bridging with low molecular weight heparin. All EMRs were performed when the INR was

Introduction: Perioperative complications influence long- and short-term outcomes after esophagectomy. The absence of a standardized system for defining and recording complications and quality measures after esophageal resection has meant that there is wide variation in evaluating their impact on these outcomes. Methods: The Esophageal Complications Consensus Group comprised 21 high-volume esophageal surgeons from 14 countries, supported by all the major thoracic and upper gastrointestinal professional societies. Delphi surveys and group meetings were used to achieve a consensus on standardized methods for defining complications and quality measures that could be collected in institutional databases and national audits. Results: A standardized list of complications was created to provide a template for recording individual complications associated with esophagectomy. Where possible, these were linked to preexisting international definitions. A Delphi survey facilitated production of specific definitions for anastomotic leak, conduit necrosis, chyle leak, and recurrent nerve palsy. An additional Delphi survey documented consensus regarding critical quality parameters recommended for routine inclusion in databases. These quality parameters were documentation on mortality, comorbidities, completeness of data collection, blood transfusion, grading of complication severity, changes in level of care, discharge location, and readmission rates. Conclusions: The proposed system for defining and recording perioperative complications associated with esophagectomy provides an infrastructure to standardize international data collection and facilitate future comparative studies and quality improvement projects.

SUMMARY The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor–Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749–1.1090) or time to recurrence (HR 0.973 95%CI 0.768–1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731–1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P

OBJECTIVES: The International Classification of Diseases 10th Revision (ICD-10) system used in the English hospital administrative database (Hospital Episode Statistics (HES)) does not contain a specific code for oesophageal high-grade dysplasia (HGD). The aim of this paper was to examine how patients with HGD were coded in HES and whether it was done consistently.SETTING: National population-based cohort study of patients with newly diagnosed with HGD in England. The study used data collected prospectively as part of the National Oesophago-Gastric Cancer Audit (NOGCA). These records were linked to HES to investigate the pattern of ICD-10 codes recorded for these patients at the time of diagnosis.PARTICIPANTS: All patients with a new diagnosis of HGD between 1 April 2013 and 31 March 2014 in England, who had data submitted to the NOGCA.OUTCOMES MEASURED: The main outcome assessed was the pattern of primary and secondary ICD-10 diagnostic codes recorded in the HES records at endoscopy at the time of diagnosis of HGD.RESULTS: Among 452 patients with a new diagnosis of HGD between 1 April 2013 and 31 March 2014, Barrett's oesophagus was the only condition coded in 200 (44.2%) HES records. Records for 59 patients (13.1%) contained no oesophageal conditions. The remaining 193 patients had various diagnostic codes recorded, 93 included a diagnosis of Barrett's oesophagus and 57 included a diagnosis of oesophageal/gastric cardia cancer.CONCLUSIONS: HES is not suitable to support national studies looking at the management of HGD. This is one reason for the UK to adopt an extended ICD system (akin to ICD-10-CM).

textabstractBackground: The primary aim of this study was to compare survival from neoadjuvant chemoradiotherapy plus surgery (NCRS) versus neoadjuvant chemotherapy plus surgery (NCS) for the treatment of esophageal or junctional adenocarcinoma. The secondary aims were to compare pathological effects, short-term mortality and morbidity, and to evaluate the effect of lymph node harvest upon survival in both treatment groups. Methods: Data were collected from 10 European centers from 2001 to 2012. Six hundred and eight patients with stage II or III oesophageal or oesophago-gastric junctional adenocarcinoma were included; 301 in the NCRS group and 307 in the NCS group. Propensity score matching and Cox regression analyses were used to compensate for differences in baseline characteristics. Results: NCRS resulted in significant pathological benefits with more ypT0 (26.7% versus 5%; P < 0.001), more ypN0 (63.3% versus 32.1%; P < 0.001), and reduced R1/2 resection margins (7.7% versus 21.8%; P < 0.001). Analysis of short-term outcomes showed no statistically significant differences in 30-day or 90-day mortality, but increased incidence of anastomotic leak (23.1% versus 6.8%; P < 0.001) in NCRS patients. There were no statistically significant differences between the groups in 3-year overall survival (57.9% versus 53.4%; Hazard Ratio (HR)=0.89, 95%C.I. 0.67-1.17, P=0.391) nor disease-free survival (52.9% versus 48.9%; HR=0.90, 95%C.I. 0.69-1.18, P=0.443). The pattern of recurrence was also similar (P=0.660). There was a higher lymph node harvest in the NCS group (27 versus 14; P < 0.001), which was significantly associated with a lower recurrence rate and improved disease free survival within the NCS group. Conclusion: The survival differences between NCRS and NCS maybe modest, if present at all, for the treatment of locally advanced esophageal or junctional adenocarcinoma. Future large-scale randomized trials must control and monitor indicators of the quality of surgery, as the extent of lymphadenectomy appears to influence prognosis in patients treated with NCS, from this large multi-center European study.

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.

A 60-year-old woman initially presented with a history of mild haematemesis. The patient denied any dysphagia, weight loss, or fever, intake of non-steroidal anti-inflammatory drugs or excessive alcohol consumption. She did not have abdominal pain and had not observed blood in her stools or melaena. At upper endoscopy, a potential source of bleeding could not be detected, but a subepithelial mass in the mid-oesophagus was revealed. The diagnostic and therapeutic approach to subepithelial oesophageal lesions is discussed.

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.

Background: Candida albicans osteo-costochondromyelitis is a rare condition. Such pathology after esophagectomy has not been reported. Methods: Report of four cases and review of pertinent English-language literature. Results: Four patients underwent esophageal surgery via a left thoraco-abdominal approach between June, 1999 and March, 2000. After complicated post-operative courses, Candida osteomyelitis of the costochondral margin presented initially as a cutaneous sinus. Conclusions: All patients responded well to surgical debridement followed by a three-month course of oral fluconazole.

We report on the potential American demand for prize-linked savings, a savings account that also awards prizes. Our survey data suggests significant interest among individuals with little actual savings, without regular saving habits, who play lotteries extensively, and are optimistic.

Introduction Radical endoscopic ablation of Barrett’s epithelium performing 4–6 endoscopic resections during the same endoscopic session has been shown to result in complete Barrett’s ablation but has a high stricture rate (40–80%). Therefore radiofrequency ablation is preferred for the ablation of Barrett’s epithelium after endoscopic mucosal resection (EMR) of visible nodules. We investigated whether non-radical, stepwise endoscopic mucosal resection with maximal 2 endoscopic resections per endoscopic session can result in complete remission of intestinal metaplasia and dysplasia in short segment Barrett’s oesophagus. Methods We analysed our database of patients undergoing oesophageal EMR for early neoplasia in Barrett’s oesophagus from 2009 to 2014. Patients showing poorly differentiated cancer or advanced cancer (>T1sm 2 ) after staging EMR were excluded. In patients suitable for further endoscopic therapy, EMR was performed using maximal two band ligation mucosectomies per endoscopic session; thereafter followup was 3 monthly and EMR was repeated as required for Barrett’s ablation. If no dysplasia was detected after a year, the follow up interval was increased to 6 months. Results 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumour stages or were managed conservatively depending on patient’s fitness, comorbidities and choice. 91 patients with HGD (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months (8–36 months IQR). Remission of dysplasia/neoplasia was achieved in 94.5% after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s ablation in 36 patients (39.6%) in a mean of 4 sessions. 40 patients (43.9%) had a short circumferential Barrett’s segment (C Conclusion In patients with short Barrett’s segment, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow up allows complete Barrett’s ablation with very low stricture rate. Disclosure of Interest None Declared

Background Motor neurone disease (MND) is a devastating illness which leads to muscle weakness and death, usually within 2-3 years of symptom onset. Respiratory insufficiency is a common cause of morbidity, particularly in later stages of MND and respiratory complications are the leading cause of mortality in MND patients. Non Invasive Ventilation (NIV) is the current standard therapy to manage respiratory insufficiency. Some MND patients however do not tolerate NIV due to a number of issues including mask interface problems and claustrophobia. In those that do tolerate NIV, eventually respiratory muscle weakness will progress to a point at which intermittent/overnight NIV is ineffective. The NeuRx RA/4 Diaphragm Pacing System was originally developed for patients with respiratory insufficiency and diaphragm paralysis secondary to stable high spinal cord injuries. The DiPALS study will assess the effect of diaphragm pacing (DP) when used to treat patients with MND and respiratory insufficiency. Method/Design 108 patients will be recruited to the study at 5 sites in the UK. Patients will be randomised to either receive NIV (current standard care) or receive DP in addition to NIV. Study participants will be required to complete outcome measures at 5 follow up time points (2, 3, 6, 9 and 12 months) plus an additional surgery and 1 week post operative visit for those in the DP group. 12 patients (and their carers) from the DP group will also be asked to complete 2 qualitative interviews. Discussion The primary objective of this trial will be to evaluate the effect of Diaphragm Pacing (DP) on survival over the study duration in patients with MND with respiratory muscle weakness. The project is funded by the National Institute for Health Research, Health Technology Assessment (HTA) Programme (project number 09/55/33) and the Motor Neurone Disease Association and the Henry Smith Charity. Trial Registration: Current controlled trials ISRCTN53817913. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

Background Positron emission tomography combined with computed tomography (PET–CT) is increasingly being used in the staging of oesophageal cancer. Some recent reports suggest it may be used to predict survival. None of these studies, however, reported on the prognostic value of PET–CT performed before neoadjuvant chemotherapy and surgery. The aim of this study was to determine whether pretreatment PET–CT could predict survival. Methods Consecutive patients with oesophageal adenocarcinoma who underwent PET–CT before neoadjuvant chemotherapy and resection were included. Maximum standardized uptake value (SUVmax), fluorodeoxyglucose (FDG)-avid tumour length and the presence of FDG-avid local lymph nodes were determined for all patients. Kaplan–Meier survival analysis was performed and multivariable analysis used to identify independent prognostic factors. Results A total of 121 patients were included (mean age 63 years, 97 men) of whom 103 underwent surgical resection. On an intention-to-treat basis, overall survival was significantly worse in patients with FDG-avid local lymph nodes (P < 0·001). SUVmax and FDG-avid tumour length did not predict survival (P = 0·276 and P = 0·713 respectively). The presence of FDG-avid local lymph nodes was an independent predictor of poor overall survival (hazard ratio (HR) 4·75, 95 per cent confidence interval 2·14 to 10·54; P < 0·001) and disease-free survival (HR 2·97, 1·40 to 6·30; P = 0·004). Conclusion The presence of FDG-avid lymph nodes, but not SUVmax or FDG-avid tumour length, was an independent adverse prognostic factor.

Evidence for the active role of the gut in multiple organ failure has turned attention away from total parenteral nutrition back to enteral nutrition as the optimal nutritional support in the critically ill. With proper feeding protocols it is possible to feed enterally the most critically ill patients.

This paper reports on a small-scale survey of the potential American demand for prize-linked savings accounts, an account that awards prizes as part of the saving product's return. In October 2006, Centra Credit Union launched a prize-linked savings pilot. As part of that initiative, we conducted a mall intercept survey of over 500 people in Clarksville, Indiana, the community where the program was launched. This preliminary data suggests that low-to-moderate income Americans may have substantial demand for prize-linked savings, with a majority of survey participants expressing an interest in opening a prize-linked savings account. As predicted by theory and international experience, interest in prize-linked savings is greatest among people who do not have regular saving habits, who have little actual savings, who play lotteries extensively, and who are optimistic about their futures.

Introduction High grade dysplasia (HGD) is often reported after Seattle protocol biopsies have been taken or the exact position of a targeted lesion within a Barrett’s segment has not been precisely documented. We investigated how often the histology of subsequent endoscopic resection agreed with the initial biopsy of HGD. Method We searched our prospectively maintained database for patients referred for endoscopic therapy of high grade dysplasia or early cancer in Barrett’s oesophagus. All biopsies from referring hospitals had been reviewed and confirmed by our expert pathologists. Endoscopy was routinely performed using acetic acid spraying and narrow band imaging to identify and delineate lesions for endoscopic resection. Endoscopic resection was performed using band ligation mucosectomy. Results 100 patients with HGD (71) or early cancer (29) were included. In 34 (47.9%) of the patients with HGD on biopsy, no lesion or abnormality had been reported on the initial endoscopy report. In all of the cancer patients and in 70 (98.6%) of the HGD patients a suspicious lesion could be identified using advanced imaging. One patient with focal HGD but without detectable mucosal lesion was directly treated using RFA. EMR confirmed HGD in 35 of 70 (50%) patients with HGD on initial biopsy but upgraded to intramucosal in 30 patients (42.8%) and to submucosal cancer in 5 patients (7.1%). Conclusion High grade dysplasia in Barrett’s oesophagus is almost always detectable using acetic acid spraying and/or narrow band imaging. Endoscopic resection of all detected lesions before RFA is recommended due to the high risk of intramucosal and even submucosal cancer. Disclosure of interest None Declared.

Introduction Correct staging is essential in selecting patients with early oesophageal neoplasia for endoscopic therapy. We prospectively investigated the diagnostic value of endoscopic ultrasound (EUS) in predicting submucosal infiltration in early Barrett neoplasia. Methods Patients with histologically proven high grade dysplasia or intramucosal cancer who were referred for potential endoscopic treatment were included in this prospective study. All patients underwent EUS staging with radial echoendoscopic ultrasound probes (7.5 MHz). A (15 MHz) radial miniprobe was used to assess focal lesions in higher definition. Results 40 patients (31 men) were included. Thereof, 14 underwent oesophagectomy, 24 had endoscopic mucosal resection using the Duette Multiband device, 2 had both procedures. Final pathological results revealed 15 submucosa infiltrating cancers and 25 neoplastic lesions limited to the mucosa. One submucosal infiltration was missed by EUS. 5 intramucosal cancers were overstaged; 3 of these were within a stricture, one in an ulcer. For detecting submucosal invasion, EUS had a sensitivity of 93.3% (95%CI: 76.1 to 98.8%), a specificity of 84% (73.6 to 87.3%), a negative predictive value of 95.5% (83.7 to 99.2%), and a positive predictive value of 77.8% (63.4 to 82.3%). Conclusion Stricturing and ulceration may result in EUS overstaging of early oesophageal neoplasia, but this would render endoscopic therapy difficult also. Knowing these limitations EUS is useful in assessing suitability for endoscopic therapy.

Introduction Radical endoscopic ablation of Barrett’s epithelium performing 4–6 endoscopic resections during the same endoscopic session has been shown to result in complete Barrett’s ablation but has a high stricture rate (48–88%). 1–3 Therefore radiofrequency ablation is preferred for the ablation of Barrett’s epithelium after endoscopic mucosal resection (EMR) of visible nodules. We investigated whether non-radical, stepwise endoscopic mucosal resection with maximal 2 endoscopic resections per endoscopic session also resulted in complete remission of Barrett’s epithelium. Methods We analysed our database of patients undergoing oesophageal EMR for early neoplasia in Barrett’s oesophagus from 2008 to 2013. Patients undergoing surgery or palliative therapy after staging EMR showing poorly differentiated cancer or advanced cancer (>T1sm) were excluded. In patients suitable for further endoscopic therapy, EMR was performed using maximal two band ligation mucosectomies per endoscopic session. Patients were endoscopically followed up 3 monthly and EMR was repeated as required for Barrett’s ablation. If no dysplasia was detected after a year, the follow up interval was increased to 6 months. Only patients with circumferential Barrett’s length of more than 5 cm underwent radiofrequency ablation. Results 83 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 25 patients underwent surgery/chemotherapy due to submucosal or more advanced tumour stages or were managed conservatively depending on patient’s fitness, comorbidities and choice. 58 patients with HGD (21), intramucosal (22) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months (8–36 months IQR). Remission of dysplasia/neoplasia was achieved in 96.5%. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s ablation in 28 patients (48.3%) in a median of 4 sessions (IQR 2–5). 31 patients (53.4%) had a short Barrett’s segment ( Conclusion Stepwise, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow up allows complete Barrett’s ablation with very low stricture rate in patients with short Barrett’s segment. References van Vilsteren FG, Pouw RE, Seewald S et al . Gut 2011;60:765–73 Alvarez Herrero L, Pouw RE, van Vilsteren FG et al . Endoscopy 2011;43:177–83 Pouw RE, Seewald S, Gondrie JJ et al . Gut 2010;59:1169–77 Disclosure of Interest None Declared.

Introduction Endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is now considered standard for treatment of high grade dysplasia (HGD) and intramucosal cancer in Barrett’s oesophagus (BE). Complete ablation of the Barrett’s epithelium is recommended to reduce the risk of metachronous neoplasia. However, RFA is an expensive treatment modality, often requiring repeat procedures and endoscopic surveillance thereafter and may not be necessary in all patients. Methods We analysed our database of oesophageal EMR procedures performed for HGD or early cancer from 2008 to 2012. Patients’ demographics, Barrett’s length, histology, number of procedures, remission and complication were assessed. All patients referred for endoscopic treatment of early Barrett’s neoplasia were investigated using EUS to exclude obvious infiltration of deeper structures. EMR was performed using band ligation mucosectomy. Patients were followed up 3 monthly with endoscopy and EMR repeated as required. If no dysplasia was found after a year, follow up interval was increased to 6 months. Results 64 patients underwent EMR for HGD (20) or early oesophageal cancer (44) in BE. 149 EMR’s were performed. 48 patients were male (75%), mean age was 70.6years (range 30–87years). 20 patients (31%) with either submucosal or deeper infiltration or poor differentiation in the EMR specimen underwent surgery/chemotherapy or were conservatively managed depending on patient’s fitness, comorbidities and choice. Mean follow-up of the remaining 44 patients undergoing endoscopic therapy was 22.7 month (range 1–55 months). Remission of dysplasia/neoplasia was achieved in 97.9%. Stepwise EMR during follow up resulted in complete ablation of BE in 18 patients (40%) in a mean of 4 sessions. All patients with complete endoscopic Barrett’s ablation had an initial maximal Barrett lengths 5cm) received RFA and 7 others are awaiting the procedure. The overall complication rate was low (6.7%) including a stricture after RFA (0.7%), 8 procedural (5.3%, none Hb relevant) and a delayed bleeding (0.7%) but no perforations. All complications were managed endoscopically. Conclusion Oesophageal EMR is a safe procedure which can achieve remission of neoplasia. In short segment Barrett’s oesophagus it can also result in complete ablation of BE. Stepwise endoscopic resection for ablation has a low complication rate when performed in 3 monthly follow-up intervals. Disclosure of Interest None Declared

Introduction Endoscopic mucosal resection (EMR) has become an established treatment modality in the managment of patients with high grade dysplastic lesions and intramucosal cancer in Barrett oesophagus. The mucosal defect caused by the endoscopic resection usually takes several weeks to heal. There is no data whether this procedure is also safe for patients requiring anticoagulation. The aim of the study was to investigate the risk of acute and delayed bleeding in patients on anticoagulation undergoing EMR for treatment of early neoplasia in Barrett oesophagus. We compared the complication rate of EMR in patients taking warfarin as anticoagulants with that of a control group. Methods Warfarin was stopped 5 days before the planned EMR and restarted on the evening of the procedure day. Patients with high risk conditions such as recent pulmonary thromboemboli received bridging with low molecular weight heparin. All EMRs were performed when the INR was Results 34 EMRs were performed in nine patients requiring anticoagulation. 8 were on warfarin due to atrial fibrillation, one took warfarin after pulmonary embolism. One patient on warfarin was readmitted 10 days after EMR with haematemesis, melaena and an drop in haemoglobin >5 g/dl caused by bleeding from an EMR resection ulcer; the bleeding had settled spontaneously at the time of endoscopy. Out of 138 EMRs in 35 controls, five acute bleeding events occurred during EMR which required treatment by clipping, coagulation grasper or heater probe. No delayed bleeding event occurred in the control group. The maximal diameter of the resected specimen did not differ between anticoagulated patients and controls (median 17 mm; 25%>75% percentile: 15–18 mm vs 17 mm; 25%>75% percentile: 15–20 mm; p=0.68). No perforations were observed in either groups. The number of bleeding events did not differ between groups (p=0.85), neither for acute (p=0.60) or delayed bleeding (p=0.46). Conclusion EMR of early oesophageal neoplasia can be safely performed in patients requiring anticoagulation when warfarin is discontinued 5 days before the endoscopic intervention and reinstituted on the evening of the procedure day. Competing interests None declared.

SummaryBackgroundNon-invasive ventilation is part of the standard of care for treatment of respiratory failure in patients with amyotrophic lateral sclerosis (ALS). The NeuRx RA/4 Diaphragm Pacing System has received Humanitarian Device Exemption approval from the US Food and Drug Administration for treatment of respiratory failure in patients with ALS. We aimed to establish the safety and efficacy of diaphragm pacing with this system in patients with respiratory muscle weakness due to ALS.MethodsWe undertook a multicentre, open-label, randomised controlled trial at seven specialist ALS and respiratory centres in the UK. Eligible participants were aged 18 years or older with laboratory supported probable, clinically probable, or clinically definite ALS; stable riluzole treatment for at least 30 days; and respiratory insufficiency. We randomly assigned participants (1:1), via a centralised web-based randomisation system with minimisation that balanced patients for age, sex, forced vital capacity, and bulbar function, to receive either non-invasive ventilation plus pacing with the NeuRx RA/4 Diaphragm Pacing System or non-invasive ventilation alone. Patients, carers, and outcome assessors were not masked to treatment allocation. The primary outcome was overall survival, defined as the time from randomisation to death from any cause. Analysis was by intention to treat. This trial is registered, ISRCTN number 53817913.FindingsBetween Dec 5, 2011, and Dec 18, 2013, we randomly assigned 74 participants to receive either non-invasive ventilation alone (n=37) or non-invasive ventilation plus diaphragm pacing (n=37). On Dec 18, 2013, the Data Monitoring and Ethics Committee (DMEC) recommended suspension of recruitment on the basis of overall survival figures. Randomly assigned participants continued as per the study protocol until June 23, 2014, when the DMEC advised discontinuation of pacing in all patients. Follow-up assessments continued until the planned end of the study in December, 2014. Survival was shorter in the non-invasive ventilation plus pacing group than in the non-invasive ventilation alone group (median 11·0 months [95% CI 8·3–13·6] vs 22·5 months [13·6–not reached]; adjusted hazard ratio 2·27, 95% CI 1·22–4·25; p=0·009). 28 (76%) patients died in the pacing group and 19 (51%) patients died in the non-invasive ventilation alone group. We recorded 162 adverse events (5·9 events per person-year) in the pacing group, of which 46 events were serious, compared with 81 events (2·5 events per person-year) in the non-invasive ventilation alone group, of which 31 events were serious.InterpretationAddition of diaphragm pacing to standard care with non-invasive ventilation was associated with decreased survival in patients with ALS. Our results suggest that diaphragmatic pacing should not be used as a routine treatment for patients with ALS in respiratory failure.FundingThe National Institute for Health Research Health Technology Assessment Programme; the Motor Neurone Disease Association of England, Wales, and Northern Ireland.