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Introduction The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019. Methods Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared. Results In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period. Conclusions Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer.

Patients with esophageal or gastroesophageal junction (GEJ) cancer who fail to respond to chemoradiotherapy have a poor clinical prognosis. Recent clinical trials have investigated the use of immune checkpoint inhibitors in these patients. The use of programmed cell death protein 1 (PD-1) inhibitors has emerged as exciting therapeutic options in the curative and palliative setting of other solid tumors. We assessed the efficacy and safety of PD-1 inhibitors in esophageal and GEJ cancers. This systematic review was performed in accordance with the PRISMA guidelines. A comprehensive electronic literature search from the EMBASE, Pubmed, Scopus, MEDLINE, and Google Scholar databases was conducted up to 25 July 2021. This review identified 11 eligible studies reporting outcomes of 3451 patients treated with PD-1 blockade compared with 2286 patients treated with either a placebo or the standard regimen of chemotherapy. Clinically significant improvements in median overall survival have been demonstrated in advanced and metastatic esophageal and GEJ cancer while maintaining acceptable safety profiles. Promising survival data have also recently emerged from PD-1 blockade in the adjuvant setting. PD-1 blockade in esophageal and GEJ cancer has delivered impressive survival benefit while remaining well tolerated. Its use in the adjuvant setting will further advance treatment options, and more advancements in this area of therapy are highly anticipated. However, further characterization of the PD-1/programmed death ligand-1 pathway and elucidation of biomarkers to predict response are required to optimize patient selection.

Introduction High quality surgery remains the cornerstone of treating oesophago-gastric malignancy. Recent work from the Dutch Upper-gastrointestinal Cancer Audit (DUCA) have defined ten surgical and perioperative ‘textbook’ parameters that correlate with improved overall survival. The aim of this project was to examine the proportion of patients attaining ‘textbook’ outcomes for oesophagectomy and gastrectomy in our unit before and after the introduction of national key performance indicators (KPIs). Method A retrospective review of all oesophagectomies and gastrectomies from January 2010 until June 2019 was performed. Clinical, pathological, perioperative, morbidity and mortality outcomes were recorded. 10 ‘textbook’ parameters were studied pre- and post-KPI introduction. Result 269 and 284 patients underwent oesophagectomy and gastrectomy respectively, 167 pre-KPI and 386 post-KPI. There were no significant differences in age (67.6 vs 66.4 years, p=0.6), gender (71% male, 29% female vs 68% male, 22% female, p=0.48), ASA grade (p=0.6) or tumour stage (p=0.37) pre- and post-KPI. In the pre-KPI era, 28/167 (17%) patients achieved all ten textbook parameters, compared with 157/386, (41%, p=0.001) post-KPI. This compares favourably to DUCA ‘textbook’ data. There was an improvement in adequate lymphadenectomy (56% vs 83%, p=0.002), a reduction in margin positivity (21% vs 7%, p= 0.001) and peri-operative mortality (6% vs 2%, p=0.03) post-KPI. Conclusion There has been a significant improvement in perioperative outcomes in esophagectomy following the introduction of national KPIs in our unit. The number of patients achieving ‘textbook’ outcomes is comparable with international standards. The identification of textbook parameters allows further focus for future quality improvement initiatives. Take-home message National KPIs improve peri-operative outcomes in oesophago-gastric cancer.

Introduction Textbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival. Methods 269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models. Results Patients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters. Conclusion Minimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter.

BACKGROUND: In early 2020, the COVID-19 pandemic significantly altered management of surgical patients globally. International guidelines recommended that non-operative management be implemented wherever possible (e.g. in proven uncomplicated appendicitis) to reduce pressure on healthcare services and reduce risk of peri-operative viral transmission. We sought to compare our management and outcomes of appendicitis during lockdown vs a non-pandemic period. METHODS: All presentations to our department with a clinical diagnosis of acute appendicitis between 12/03/2020 and 30/06/2020 were compared to the same 110-day period in 2019. Quantity and severity of presentations, use of radiological investigations, rate of operative intervention and histopathological findings were variables collected for comparison. RESULTS: There was a reduction in appendicitis presentations (from 74 to 56 cases), and an increase in radiological imaging (from 70.27% to 89.29%) (P = 0.007) from 2019 to 2020. In 2019, 93.24% of patients had appendicectomy, compared to 71.42% in 2020(P

High quality surgery remains the cornerstone of treating esophageal malignancy. Recent work from the Dutch Upper-gastrointestinal Cancer Audit have defined ten surgical and perioperative “textbook” parameters that correlate with improved overall survival in patients undergoing esophageal resection. In 2013, national key performance indicators were introduced in Ireland against which esophageal cancer resection was to be benchmarked. This project examines the effect of introducing the KPIs on the proportion of patients attaining “textbook” outcomes for esophagectomy. Methods A retrospective review of all esophagectomies and from January 2010 until June 2019 was performed. Clinical, pathological, perioperative, morbidity and mortality outcomes were recorded. 10 “textbook” parameters were studied pre- and post-KPI introduction. Results 269 underwent esophagectomy, 77 pre-KPI and 192 post-KPI. There were no significant differences in age (67.6 vs 66.4 years, p = 0.6), gender (72% male, 28% female vs 67% male, 23% female, p = 0.43), ASA grade (p = 0.6) or tumour stage (p = 0.37) pre- and post-KPI. In the pre-KPI era, 13/77 (17%) patients achieved all ten textbook parameters, compared with 79/192, (41%, p = 0.001) post-KPI. This compares favourably to DUCA “textbook” data. There was an improvement in adequate lymphadenectomy (56% vs 83%, p = 0.002), a reduction in margin positivity (21% vs 7%, p = 0.001) and reduced peri-operative mortality (6% vs 2%, p = 0.03) post-KPI. Conclusion There has been a significant improvement in perioperative outcomes in esophagectomy following the introduction of national KPIs in our unit. The number of patients achieving “textbook” outcomes is comparable with international standards. The identification of textbook parameters allows further focus for future quality improvement initiatives.

Esophageal cancer is the 9th most common cause of cancer globally with a mortality:incidence ratio of 0.88 and a 5 year mortality rate of 19%. Herceptin, a HER2 targeted monoclonal antibody, is approved for use in metastatic HER2+ gastroesophageal carcinoma. To further examine the benefits of HER family inhibition in esophageal cancer, the effects of pan-HER family TKIs and standard chemotherapy in HER2+ and HER2-low cell line models were examined. Methods Two cell lines, OE19 (HER2+) and FLO-1 (HER2-low) were used to examine the effect of the standard FLOT chemotherapy regimen (5 flurouracil (5FU), oxaliplatin and docetaxel) and pan-HER TKIs neratinib and poziotinib. All compounds were from commercial sources. 2D acid phosphatase-based proliferation assays were utilised to assess the anti-proliferative effects of these agents. Triplicates of each assay were performed and standard deviations were determined. IC50 values were calculated using Calcusyn ® software. Results The OE19 cell line demonstrated a high sensitivity to neratinib and poziotinib with IC50 values of 3.426+/−0.187 nM and 0.307 +/−0.051 nM), respectively. IC50 values for neratinib (0.147+/−0.080 μM) and poziotinib (2.4+/−0.471 μM) were significantly higher (p Conclusion The HER2+ cell line was significantly more sensitive to the pan-HER family TKIs neratinib and poziotinib, compared to the HER2-low cell line. This may indicate a potential use for pan-HER family TKIs in HER2+ esophageal cancer. Further work is being conducted to assess potential synergy between pan-HER family TKIs and chemotherapy in these models.

Background Advances in peri-operative oncological treatment, surgery and peri-operative care have improved survival for patients with oesophagogastric cancers. Neoadjuvant cancer treatment (NCT) reduces physical fitness, which may reduce both compliance and tolerance of NCT as well as compromising post-operative outcomes. This is particularly detrimental in a patient group where malnutrition is common and surgery is demanding. The aim of this trial is to assess the effect on physical fitness and clinical outcomes of a comprehensive exercise training programme in patients undergoing NCT and surgical resection for oesophagogastric malignancies. Methods The PERIOP-OG trial is a pragmatic, multi-centre, randomised controlled trial comparing a peri-operative exercise programme with standard care in patients with oesophagogastric cancers treated with NCT and surgery. The intervention group undergo a formal exercise training programme and the usual care group receive standard clinical care (no formal exercise advice). The training programme is initiated at cancer diagnosis, continued during NCT, between NCT and surgery, and resumes after surgery. All participants undergo assessments at baseline, post-NCT, pre-surgery and at 4 and 10 weeks after surgery. The primary endpoint is cardiorespiratory fitness measured by demonstration of a 15% difference in the 6-min walk test assessed at the pre-surgery timepoint. Secondary endpoints include measures of physical health (upper and lower body strength tests), body mass index, frailty, activity behaviour, psychological and health-related quality of life outcomes. Exploratory endpoints include a health economics analysis, assessment of clinical health by post-operative morbidity scores, hospital length of stay, nutritional status, immune and inflammatory markers, and response to NCT. Rates of NCT toxicity, tolerance and compliance will also be assessed. Discussion The PERIOP-OG trial will determine whether, when compared to usual care, exercise training initiated at diagnosis and continued during NCT, between NCT and surgery and then during recovery, can maintain or improve cardiorespiratory fitness and other physical, psychological and clinical health outcomes. This trial will inform both the prescription of exercise regimes as well as the design of a larger prehabilitation and rehabilitation trial to investigate whether exercise in combination with nutritional and psychological interventions elicit greater benefits. Trial registration ClinicalTrials.gov: NCT03807518. Registered on 1 January 2019

Obesity and type 2 diabetes mellitus (T2DM) represent significant healthcare burdens. Surgical management is superior to traditional medical therapy. Laparoscopic sleeve gastrectomy (LSG) and gastric bypass (both Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) are the most commonly performed metabolic procedures. It remains unclear which gives the optimal quality-of-life pay-off in the context of T2DM. This study compares LSG, RYGB, and OAGB in the management of T2DM and obesity using modeled decision analysis. Alternative approaches were assessed considering efficacy of interventions, post-operative complications, and quality of life outcomes to determine the optimal approach. Modeled decision analysis was performed from the patent’s perspective comparing best medical management (MM), SG, RYGB, OAGB, and LAGB. The base case is a 40-year-old female with a body mass index (BMI) of 40 and T2DM. Input variables were calculated based on published decision analyses and a literature review. Utilities were based on previous studies. Sensitivity analysis was performed. The payoff was quality-adjusted life years (QALYs) 5 years from intervention. TreeAge Pro modeling software was used for analysis. In 5-years post-procedure, OAGB gave the optimal QALY payoff of 3.65 QALYs (reviewer 2). RYGB gave 3.47, SG gave 3.08, LAGB gave 2.62 and MM 2.45 QALYs. Three input variables proved sensitive. RYGB is optimal if its metabolic improvement rates exceed 86%. It is also optimal if metabolic improvement rates in OAGB drop below 71.8% or if the utility of OAGB drops below 0.759. OAGB gives the optimal QALY payoff in treatment of T2DM. RYGB and SG also improve metabolic outcomes and remain viable options in selected patients.

Enhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery. The PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed. A total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5 min in operative time (p

Summary Esophageal cancer stenting offers symptomatic relief for patients suffering from dysphagia. There are limited data to support their use to relieve dysphagia and improve nutrition during neoadjuvant therapy with some concern that they may negatively impact oncological outcomes. The aim of this systematic review was to quantify the impact of esophageal stents on outcomes prior to resection with curative intent. A literature search was performed using Embase, Medline, PubMed, PubMed Central, the Cochrane library for articles pertaining to esophageal stent use prior to or during neoadjuvant chemotherapy or chemoradiotherapy in patients planned for curative esophagectomy. Data extracted included basic demographics, clinical, nutritional and oncologic outcomes. A total of 9 studies involving 465 patients were included. Esophageal stent use resulted in a significant improvement in mean dysphagia scores in the immediate post stent period but failed to demonstrate any positive changes in weight, body mass index (BMI) or albumin. Only 33% of stented patients ultimately progressed to potential curative surgical resection and stents were associated with reduced R0 resection rates and lower overall survival. This systematic review shows that, although esophageal stenting is associated with improvements in dysphagia during neoadjuvant therapy, their effect on improving patient nutritional status is less clear and they may be associated with poorer long-term oncological outcomes. Stents should be used with caution in patients who are being considered for potentially curative resection of esophageal malignancies and other strategies of nutritional supplementation should be considered.

Summary Barrett’s esophagus (BE) is the main pathological precursor of esophageal adenocarcinoma (EAC). Progression to high-grade dysplasia (HGD) or EAC from nondysplastic BE (NDBE), low-grade dysplasia (LGD) and indefinite for dysplasia (IND) varies widely between population-based studies and specialized centers for many reasons, principally the rigor of the biopsy protocol and the accuracy of pathologic definition. In the Republic of Ireland, a multicenter prospective registry and bioresource (RIBBON) was established in 2011 involving six academic medical centers, and this paper represents the first report from this network. A detailed clinical, endoscopic and pathologic database registered 3,557 patients. BE was defined strictly by both endoscopic evidence of Barrett’s epithelium and the presence of specialized intestinal metaplasia (SIM). A prospective web-based database was used to gather information with initial and follow-up data abstracted by a data manager at each site. A total of 2,244 patients, 1,925 with no dysplasia, were included with complete follow-up. The median age at diagnosis was 60.5 with a 2.1:1 male to female ratio and a median follow-up time of 2.7 years (IQR 1.19–4.04), and 6609.25 person years. In this time period, 125 (5.57%) progressed to HGD/EAC, with 74 (3.3%) after 1 year of follow-up and 38 (1.69%) developed EAC, with 20 (0.89%) beyond 1 year. The overall incidence of HGD/EAC was 1.89% per year; 1.16% if the first year is excluded. The risk of progression to EAC alone overall was 0.57% per year, 0.31% excluding the first year, and 0.21% in the 1,925 patients who had SIM alone at diagnosis. Low-grade dysplasia (LGD) progressed to HGD/EAC in 31% of patients, a progression rate of 12.96% per year, 6.71% with the first year excluded. In a national collaboration of academic centers in Ireland, the progression rate for NDBE was similar to recent population studies. Almost one in two who progressed was evident within 1 year. Crucially, LGD diagnosed and confirmed by specialist gastrointestinal pathologists represents truly high-risk disease, highlighting the importance of expertise in diagnosis and management, and providing indirect support for ablative therapies in this context.

SUMMARYCancers of the esophagus and stomach are challenging to treat. With the advent of neoadjuvant therapies, patients frequently have a preoperative window with potential to optimize their status before major resectional surgery. It is unclear as to whether a prehabilitation or optimization program can affect surgical outcomes. This systematic review appraises the current evidence for prehabilitation and rehabilitation in esophagogastric malignancy. A literature search was performed according to PRISMA guidelines using PubMed, EMBASE, Cochrane Library, Google Scholar, and Scopus. Studies including patients undergoing esophagectomy or gastrectomy were included. Studies reporting on at least one of aerobic capacity, muscle strength, quality of life, morbidity, and mortality were included. Twelve studies were identified for inclusion, comprising a total of 937 patients. There was significant heterogeneity between studies, with a variety of interventions, timelines, and outcome measures reported. Inspiratory muscle training (IMT) consistently showed improvements in functional status preoperatively, with three studies showing improvements in respiratory complications with IMT. Postoperative rehabilitation was associated with improved clinical outcomes. There may be a role for prehabilitation among patients undergoing major resectional surgery in esophagogastric malignancy. A large randomized controlled trial is warranted to investigate this further.

Background Despite having considerable influence over resource allocation clinicians possess poor knowledge of healthcare costs. This study evaluated surgeons' cost-awareness with regard to surgical equipment and assessed attitudes towards health economics training using survey format. Materials and methods An online survey was distributed to 326 surgeons across a range of specialties in Ireland. Respondents were asked about their surgical expertise, previous training in health economics, and its role in the surgical curriculum. They were also asked to estimate the recommended retail price (RRP) of 17 commonly used items of surgical equipment. Answers within ±25% of the RRP were considered correct. Results Of 140 respondents, 62 (44.3%) were on a surgical training scheme and 16 (11.4%) were consultants. Overall, surgeons correctly estimated the RRP of only 14.0% of items. There was no difference in accuracy between surgeons in later years of training compared to their junior counterparts (13.1 ± 8.8% versus 15.0 ± 8.8%, p = 0.115). The highest individual score was six out of 17 items correctly estimated. Participants overestimated the cost of low-cost items by 347.7% and underestimated the cost of high-cost items by 35.5%. Only 5.7% of participants had received undergraduate training in health economics but 75.0% felt it should be included in the curriculum. Over two-thirds said their practice would change if they had better knowledge of the cost of surgical equipment. Conclusion The majority of surgeons receive little training in health economics and have poor knowledge of the cost of surgical equipment. Most would welcome more training at both an undergraduate and postgraduate level. An opportunity exists to promote cost awareness in the operating room, which could lead to a reduction in waste and improved use of resources.

Background Obesity is a chronic disease associated with significant morbidity and mortality. Bariatric surgery has been shown to significantly reduce both morbidity and mortality. Numerous surgical strategies exist, but the most frequently used worldwide are adjustable gastric banding, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB). It is not clear which of these strategies provides the optimal quality-of-life pay-off. Objective Modeled decision analysis allows comparison of different treatment interventions allowing for plausible differences in input variables. This facilitates establishment of the optimal intervention under numerous conditions. Setting University Hospital, Ireland. Methods Modeled decision analysis was performed from the patient's perspective comparing best medical therapy, adjustable gastric banding, SG, and RYGB. Input variables were calculated based on previously published decision analyses and a systematic search of obesity-related literature. Utilities were based on previously published studies. One-way sensitivity analysis was performed. Sensitive variables underwent 3-way analysis. Results The optimal treatment strategy in the base case was RYGB with a quality-adjusted life-year payoff (QALY) of 1.53 QALYs at 2 years postprocedure. Sleeve gastrectomy provided 1.49 QALYs. Medical therapy and adjustable gastric banding provided .98 and .96 QALYs, respectively. Rate of complications in RYGB and the utility of SG and RYGB proved sensitive. If complication rates are high, SG becomes the optimal strategy. Sensitive thresholds were established for the utility of SG and RYGB at .804 and .78, respectively. Conclusion SG and RYGB offer similar outcomes in terms of QALY payoffs. Decision making should be in line with institutional and patient preference.

Objective: The study objectives were to analyze the impact of the number of lymph nodes (LNs) reported as resected (NLNr) and the number of LNs invaded (NLNi) on the prognosis of esophageal cancer (EC) after neoadjuvant chemoradiotherapy. Background: Pathological LN status is a major disease prognostic factor and marker of surgical quality. The impact of neoadjuvant chemoradiation (nCRT) on LN status remains poorly studied in EC. Methods: Post hoc analysis from a phase III randomized controlled trial comparing nCRT and surgery (group nCRT) to surgery alone (group S) in stage I and II EC (NCT00047112). Only patients who underwent surgical resection were considered (n = 170). Results: nCRT resulted in tumoral downstaging (pT0, 40.7% vs 1.1%, P 3 vs 0) 3.5, 95% CI: 2.0-6.2, P = 15) 0.95, 95% CI: 0.6-1.4, P = 0.807 and HR ( = 23) 1.4, 95% CI: 0.9-2.0, P = 0.131] did not. In Poisson regression analysis, nCRT was an independent predictive variable for reduced NLNr [exp(coefficient) 0.80, 95% CI: 0.66-0.96, P = 0.018]. Conclusions: nCRT is not only responsible for disease downstaging but also predicts fewer LNs being identified after surgical resection for EC. This has implications for the current quality criteria for surgical resection

Background Segmental replacement of the esophagus (SRE) is challenging. Allogenic aorta (AA) has shown promising remodeling abilities when used as an esophageal substitute. The aim of this study was to evaluate the feasibility and results of esophageal replacement with fascial flap–wrapped AA segments in a novel rabbit model. Materials and methods Seven Geant des Flandres rabbits and one New Zealand rabbit served as thoracic aorta donors, and 25 New Zealand rabbits were used as recipients. One to 3 wk before esophageal replacement either cryopreserved or fresh thoracic aortic segments were wrapped in thoracic wall fascia to generate revascularization. In an attempt to optimize the model, step-by-step modifications concerning perioperative and postoperative management of the recipients were made as results accumulated. Microscopic evaluation was focused on the viability of aortic segments and neoangiogenesis originating from the fascia. Results Survival after SRE was poor. Most recipients died within 1 wk, mainly from upper digestive tract hypomotility. Microscopically, AAs were severely necrosed. In one recipient sacrificed on day 16, the edges of the graft became evanescent. In these areas, esophageal reepithelialization directly covered the fascia, in which unexpected smooth muscle cells were found, suggestive of the first stages of esophageal remodeling of the graft. Conclusions Results for SRE using fascial-wrapped AAs in rabbits were disappointing. The transposition of this approach to larger animals might result in longer survival, increasing the possibility for more complete graft remodeling.

Endoscopic ultrasound-guided gallbladder drainage is a novel method of treating acute cholecystitis in patients deemed too high risk for surgery. It involves endoscopic stent placement between the gallbladder and the alimentary tract to internally drain the infection and is an alternative to percutaneous cholecystostomy (PC). This meta-analysis assesses the clinical outcomes of high-risk patients undergoing endoscopic drainage with an acute cholecystoenterostomy (ACE) compared with PC in acute cholecystitis. A literature search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Databases were searched for studies reporting outcomes of patients undergoing ACE or PC. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). A total of 1593 citations were reviewed; five studies comprising 495 patients were ultimately selected for analysis. There were no differences in technical or clinical success rates between the two groups on pooled meta-analysis. ACE had significantly lower post-procedural pain scores (mean difference − 3.0, 95% CI − 2.3 to − 3.6, p

Esophagectomy remains a surgical operation with the potential for significant morbidity and mortality. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and enhance patient recovery. Whether minimally invasive techniques decrease morbidity while maintaining the quality of the oncological resection remains a topic of debate. Globally, minimally invasive esophagectomy (MIE) has been shown to be feasible and safe, with outcomes similar to open esophagectomy. Assessments of the current role of MIO have largely been made based on retrospective comparative studies and many single institution series. These generally have reported that MIO reduces blood loss, shortens time in high-dependency care, and decreases length of hospital stay. Lymph node yields appear to be similar with a minimally invasive resection compared to open extended lymphadenectomy, and MIO cancer outcomes are comparable. MIO will be a major component of the future esophageal surgeons’ armamentarium, but should continue to be carefully assessed. Randomized trials comparing MIO versus open resection in esophageal cancer are urgently needed, with only one phase III (TIME) trial having been published with the final results from a further phase III trial (MIRO trial) being keenly awaited.

BACKGROUND: Postoperative intra-abdominal adhesions after GI surgery constitute a major burden for health care provision globally, causing chronic abdominal symptoms and necessitating repeated surgical intervention. OBJECTIVE: This systematic review examines safety and efficacy data for current anti-adhesion strategies after GI surgery. DATA SOURCES: PubMed, Medline, and Embase databases were searched for randomized control trials and nonrandomized clinical studies of anti-adhesion products from January 1980 to October 2013. STUDY SELECTION: A list of predefined search terms was combined with the Cochrane Highly Sensitive Search Strategy to identify studies. INTERVENTION: The use of an anti-adhesion strategy was investigated. MAIN OUTCOME MEASURES: The primary outcome was the safety profile of anti-adhesion products. Secondary outcomes included the analysis of the reduction in the incidence, extent, and severity of adhesions; incidence of bowel obstruction; quality-of-life data; and oncological outcomes. RESULTS: In total, 24 articles were included in the qualitative analysis: 17 randomized controlled trials and 7 nonrandomized studies, reporting on 5 anti-adhesion products. Data suggest that anti-adhesive products may be used safely; however, hyaluronic acid-based products should not be placed in contact with an anastomosis. The most studied product, a hyaluronic acid/carboxymethylcellulose membrane, reduces the incidence, extent, and severity of adhesions but without strong evidence of prevention of bowel obstruction. LIMITATIONS: The size and quality of available studies varied greatly, reflected by the Jadad and MINORS scores. The majority of studies reported the use of a single product, hyaluronic acid/carboxymethylcellulose membrane. CONCLUSIONS: Limiting adhesion formation after GI surgery is feasible. More evidence is needed regarding the efficacy in reducing chronic abdominal symptoms, repeated operative intervention, and improving quality of life.

Purpose Although often investigated in locally advanced esophageal cancer (EC), the impact of neoadjuvant chemoradiotherapy (NCRT) in early stages is unknown. The aim of this multicenter randomized phase III trial was to assess whether NCRT improves outcomes for patients with stage I or II EC. Methods The primary end point was overall survival. Secondary end points were disease-free survival, postoperative morbidity, in-hospital mortality, R0 resection rate, and prognostic factor identification. From June 2000 to June 2009, 195 patients in 30 centers were randomly assigned to surgery alone (group S; n = 97) or NCRT followed by surgery (group CRT; n = 98). CRT protocol was 45 Gy in 25 fractions over 5 weeks with two courses of concomitant chemotherapy composed of fluorouracil 800 mg/m2 and cisplatin 75 mg/m2. We report the long-term results of the final analysis, after a median follow-up of 93.6 months. Results Pretreatment disease was stage I in 19.0%, IIA in 53.3%, and IIB in 27.7% of patients. For group CRT compared with group S, R0 resection rate was 93.8% versus 92.1% (P = .749), with 3-year overall survival rate of 47.5% versus 53.0% (hazard ratio [HR], 0.99; 95% CI, 0.69 to 1.40; P = .94) and postoperative mortality rate of 11.1% versus 3.4% (P = .049), respectively. Because interim analysis of the primary end point revealed an improbability of demonstrating the superiority of either treatment arm (HR, 1.09; 95% CI, 0.75 to 1.59; P = .66), the trial was stopped for anticipated futility. Conclusion Compared with surgery alone, NCRT with cisplatin plus fluorouracil does not improve R0 resection rate or survival but enhances postoperative mortality in patients with stage I or II EC.

Signet ring cell (SRC) tumors have a worse prognosis when compared with non-SRC tumors, and neoadjuvant chemotherapy has been suggested to be an ineffective treatment strategy. Preoperative radiochemotherapy, of already proven efficacy for esophagogastric junction adenocarcinomas (EGJA), could be an alternative neoadjuvant strategy for SRC EGJA. The aim of this retrospective study was to evaluate the survival impact of preoperative radiochemotherapy on patients with advanced resectable SRC EGJA.Of 3,010 patients registered in 21 French centers between January 1997 and January 2010, 2,670 underwent surgical resection, of whom 97 patients had a stage III SRC EGJA treated by either neoadjuvant radiochemotherapy followed by surgery (group RCT, n = 23) or primary surgery (group S, n = 74).Groups were comparable by age, sex, American Society of Anesthesiologists score, malnutrition, and cTNM stage. There was evidence of significant tumoral (p = 0.003), nodal (p0.001), and pTNM (p0.001) downstaging after radiochemotherapy. In group RCT and group S, 3-year overall survival was 51% and 21% (p = 0.002), respectively, with disease recurrence rate of 30.4% versus 59.5% (p = 0.015), respectively. In multivariate analysis the sole independent favorable prognostic factor identified was the administration of neoadjuvant radiochemotherapy (hazard ratio 0.41, p = 0.020).In the setting of locally advanced SRC EGJA, neoadjuvant radiochemotherapy is responsible for tumoral downstaging, reduced disease recurrence, and improved patient survival. A strategy of preoperative radiochemotherapy should be implemented in clinical practice to treat advanced SRC EGJA.

Objective To compare the outcomes of a strategy of surveillance versus surgical resection in patients with esophageal cancer (EC) experiencing complete clinical response (cCR) after chemoradiation (CRT). Background In EC, it remains unclear whether a strategy of surveillance or esophagectomy is appropriate after cCR to CRT. Methods From 1995 to 2009, 222 operable patients had a cCR based on the results of a computed tomographic scan, endoscopy with biopsies and, when performed, a positron emission tomographic scan. Through an intention-to-treat case-control study, 59 patients treated with CRT and surveillance (group Surv) were matched 1:2 with 118 patients treated by CRT followed by surgery (group Surg), according to age, gender, tumor location and stage, histology, American Society of Anesthesiologists score, and nutritional status. Results The 2 groups were comparable according to the matched variables (P > 0.276). In group Surg, the postoperative mortality rate was 4.2% with evidence of residual tumor in 34.6% of specimens. In group Surv, 2 salvage esophagectomies were performed. Despite the higher dose of radiotherapy received in group Surv (50 vs 45 Gys, P = 0.003), median survival was lower (31 vs 83 months, P = 0.001), with disease recurrence that was more frequent (50.8% vs 32.7%, P = 0.021), occurred earlier (7.8 vs 19.0 months, P = 0.002) and more often locoregional (46.7% vs 16.2%, P = 0.007) in nature. Surgical resection was independently associated with less recurrence [odds ratio = 0.4, 95% confidence interval (CI): 0.2-0.8, P = 0.006] and better survival (hazard ratio = 0.5, 95% CI: 0.3-0.8, P = 0.006). Conclusions Survival of EC patients with a cCR after CRT is better after surgery compared to simply surveillance. In patients of low operative risk and operable disease, surgery should be considered to improve control of locoregional disease and to overcome the inherent limitations of clinical response assessment.

Patient and technical factors influencing postoperative infectious complications after elective colorectal resections for cancer are well described. Tumor related factors, however, have not been extensively evaluated.This study aimed to measure the effect of tumor stage on postoperative surgical site and extra surgical site infections after elective colorectal cancer resection.This was a retrospective matched-cohort analysis of prospectively gathered data.The study was conducted in a tertiary referral center and a private hospital specializing in colorectal surgery.Between 2004 and 2011, 740 consecutive patients underwent elective resection for colorectal cancer in 2 centers. Patients undergoing resection for advanced tumors (group A, ≥ stage IIB, n = 177) were matched to randomly selected patients with localized disease (group L,stage IIB, n = 354). Matching variables were age, sex, American Society of Anesthesiologists score, malnutrition, and surgical approach.We compared 30-day infectious complications rates between patients with advanced (group A) and localized (group L) tumors. Multivariable logistic regression analysis was performed to identify risk factors for infectious complications.Group A had a higher overall rate of IC (44.6 vs 25.4 %, p0.001), with a higher risk of infectious complications at both the resection site (p0.001) and distant to the resection site (p = 0.015). Independent risk factors for infectious complications were advanced tumors (OR = 2.70; p0.001), obesity (OR = 1.89; p = 0.018), malnutrition (OR = 2.22; p = 0.008), and open rather than laparoscopic procedure (OR = 5.11; p0.001).This study is limited by its retrospective methodology.Advanced tumors increase the risk of infectious complications after colorectal resection, with other risk factors including malnutrition, obesity, and resection by laparotomy. Optimization of modifiable risk factors through nutritional repletion and the choice of a minimally invasive operation should be considered.

Background Often curative treatment for locally advanced resectable esophageal or gastro-esophageal junctional cancer consists of concurrent neoadjuvant radiotherapy and chemotherapy followed by surgery. Currently, one of the most commonly used chemotherapy regimens in this setting is a combination of a fluoropyrimidin and of a platinum analogue. Due to the promising results of the recent CROSS trial, another regimen combining paclitaxel and carboplatin is also widely used by European and American centers. No clinical study has shown the superiority of one treatment over the other. The objective of this Phase II study is to clarify clinical practice by comparing these two chemotherapy treatments. Our aim is to evaluate, in operable esophageal and gastro-esophageal junctional cancer, the complete resection rate and severe postoperative morbidity rate associated with these two neoadjuvant chemotherapeutic regimens (carboplatin-paclitaxel or fluorouracil-oxaliplatin-folinic acid) when each is combined with the radiation regime utilized in the CROSS trial. Methods/design PROTECT is a prospective, randomized, multicenter, open arms, phase II trial. Eligible patients will have a histologically confirmed adenocarcinoma or squamous cell carcinoma and be treated with neoadjuvant radiochemotherapy followed by surgery for stage IIB or stage III resectable esophageal cancer. A total of 106 patients will be randomized to receive either 3 cycles of FOLFOX combined to concurrent radiotherapy (41.4 Grays) or carboplatin and paclitaxel with the same radiation regimen, using a 1:1 allocation ratio. Discussion This ongoing trial offers the unique opportunity to compare two standards of chemotherapy delivered with a common regimen of preoperative radiation, in the setting of operable locally advanced esophageal or gastro-esophageal junctional tumors. Trial registration NCT02359968 (ClinicalTrials.gov) (registration date: 9 FEB 2015), EudraCT: 2014-000649-62 (registration date: 10 FEB 2014)

Evidence-based medicine continues to have an increasingly important impact on all surgical departments, with the art of publication becoming a skill in its own right and occupying an ever more central role. However, it remains a challenge for any surgeon to publish their work.The aims of this educational review are to understand why, what and where surgeons should publish and to provide surgeons with a guide regarding the publication process and the rules to be adhered to.This review targets (1) any surgeon beginning their scientific publication activity, (2) more experienced surgeons who wish to optimise their ability to have their work published and finally (3) leaders of research departments who aspire to improve the quality of their publications and their research productivity and profile.

The recent introduction of a Surgical Safety Checklist has significantly reduced the morbidity and mortality of surgery. Such a simple measure that can impact so highly on surgical outcomes causes all surgeons to pause for thought. This paper documents the introduction of a 10-step intraoperative surgical checklist (ISC) to standardize performance, decision-making, and training during laparoscopic cholecystectomy (LC). The checklist’s impact on conversion rates to open cholecystectomy (OC) is presented. In 2004, a 10-step ISC was introduced by a single consultant surgeon for the performance of LCs. Data were collected comparing LCs between 1999–2003 (period 1) and 2004–2008 (period 2). Data on sex, age, American Society of Anesthesiology grade, previous abdominal surgery, severity of gallbladder pathology, and conversion to OC were recorded. The chi-squared test with Yates correction was used to compare groups. In total, 637 LCs were performed, 277 during period 1 and 360 during period 2. Risk factors for conversion (gender, age, previous abdominal surgery, and severity of gallbladder pathology) were not significantly different in the two periods studied. The overall conversion rate to OC fell significantly in period 2 (p = 0.001). Subgroup analysis also showed a significant reduction in conversion rates in female patients (p = 0.002) and patients with grades III and IV gallbladder disease (p = 0.001). The introduction of a 10-step ISC was temporally related to reduced conversion rates to OC. The standardization of a frequently performed operation such as a LC that could potentially lead to an impact as great the one we observed warrants further attention in prospective, appropriately designed studies.

The amino acid taurine has an established role in attenuating lung fibrosis secondary to bleomycin-induced injury. This study evaluates taurine's effect on TGF-beta1 expression and the development of lung fibrosis after single-dose thoracic radiotherapy.Four groups of C57/Bl6 mice received 14 Gy thoracic radiation. Mice were treated with taurine or saline supplementation by gavage. After 10 days and 14 weeks of treatment, TGF-beta1 levels were measured in serum and bronchoalveolar lavage fluid (BALF). Lung collagen content was determined using hydroxyproline analysis.Ten days post radiotherapy, serum TGF-beta1 levels were significantly lower after gavage with taurine rather than saline (P = 0.033). BALF TGF-beta1 at 10 days was also significantly lower in mice treated with taurine (P = 0.031). Hydroxyproline content was also significantly lower at 14 weeks in mice treated with taurine (P = 0.020).This study presents novel findings of taurine's role in protecting from TGF-beta1-associated development of lung fibrosis after thoracic radiation.

International audience; BACKGROUND:Perioperative oncologic treatments provide a survival benefit for junctional and gastric adenocarcinoma (JGA) and esophageal cancer (EC). Whether neoadjuvant therapy toxicity (NTT) correlates with increased perioperative risk remains unclear. We aimed to evaluate the impact of grade III/IV NTT on postoperative and oncologic outcomes in resected upper gastrointestinal malignancies.METHODS:A multicenter retrospective analysis was performed on consecutive patients who benefited from neoadjuvant chemo(radio)therapy followed by surgery between 1997 and 2010 for JGA (first cohort, n = 653) and for EC (second cohort, n = 640). Data between patients who experienced NTT were compared to those who did not.RESULTS:NTT was associated with higher postoperative mortality after resection of JGA (P = 0.001) and after esophagectomy (P < 0.001), more non-R0 resections (JGA P = 0.019, EC P = 0.024), a decreased administration of adjuvant treatment among the JGA cohort (P = 0.012), and higher surgical morbidity (JGA P = 0.005, EC P = 0.020). Median survival was reduced in patients who experienced NTT in both cohorts (JGA P = 0.018, EC P = 0.037). After adjustment on confounding variables, NTT was independently associated with postoperative mortality in both cohorts (P ≤ 0.007).CONCLUSIONS:NTT is a predictor of postoperative mortality, correlates with higher postoperative morbidity, and negatively affects oncologic outcomes for upper gastrointestinal carcinomas.

The primary objective was to evaluate the feasibility of surgical enucleation of esophageal gastrointestinal stromal tumors (E-GISTs). Secondary objectives evaluated (i) the impact of tumor enucleation on oncological outcomes, (ii) the effect of pretherapeutic biopsy on the feasibility of E-GIST enucleation, and (iii) the impact of mucosal ulceration on outcome.E-GISTs are very rare tumors and esophageal resection has been the recommended approach. The feasibility and impact on outcomes of tumor enucleation are unknown.Through a large national multicenter retrospective study, 19 patients with E-GISTs were identified between 2001 and 2010. Patients who underwent either enucleation or esophagectomy were compared.Of over 19 patients identified with E-GISTs, curative treatment was surgical for 16 patients, with enucleation in 8 and esophagectomy in 8. In the enucleation group, median tumoral diameter was 40 mm (18-65 mm), without any mucosal ulceration, preoperative capsular ruptures, or incomplete resections. In the esophagectomy group, the median tumoral diameter was 85 mm (55-250 mm), with mucosal ulceration in 4 patients, preoperative capsular rupture in 1, and no incomplete resections. Severe postoperative complication rates were 50% and 25% in the esophagectomy and enucleation groups, respectively, with 2 postoperative deaths after esophagectomy. After a median follow-up of 6.4 years, 2 recurrences were observed after esophagectomy versus 0 after enucleation. Endoscopic biopsies did not expose patients to complications or local recurrence after enucleation. Endoscopic mucosal ulceration was associated with more aggressive tumors.E-GIST enucleation seems safe for tumors of less than 65 mm in diameter.

To date, for esophageal cancer (EC), the optimal timing of surgical procedures after neoadjuvant chemoradiation (nCRT) is not well defined. Data in rectal cancer suggest that a prolonged interval between treatment and operation may improve tumoral pathologic response, R0 resection rate, and survival. The aims of this study were to evaluate whether delaying operation after nCRT in EC increases pathologic response and has an impact on oncologic outcome or postoperative course.A total of 257 consecutive EC patients (n=161 squamous cell carcinomas and n=96 adenocarcinomas) undergoing nCRT followed by operation between 1997 and 2011 were retrospectively analyzed by the use of prospectively collected data. The patients were divided into two groups according to the median delay between nCRT and operation (7 weeks, n=122; ≥7 weeks, n=135). The impact of surgical delay on outcomes was studied through univariable and multivariable analyses.The groups were comparable regarding patient and tumor characteristics (p≥0.074). The ypT0 and R0 resection rates were similar between the two groups, as were postoperative course, median survivals, and incidence and patterns of recurrence (p≥0.332). Multivariable analysis failed to identify any impact of the surgical delay on the endpoints. Subgroup analysis according to the histologic type found similar results.After nCRT for EC, delaying operation does not affect the ypT0 rate, postoperative course, or oncologic outcome and cannot therefore be justified by these aims.

Although the signet ring cell histologic subtype (SRC) is an independent predictor of poor prognosis in advanced gastric adenocarcinomas (GA), its prognostic value in early GA remains highly controversial. The aim of the study was to evaluate the prognostic impact of SRC in mucosal and submucosal GAs.Based on a multicenter cohort of 3,010 patients operated on for GA between January 1997 and January 2010, patients with pTis or pT1 tumors were extracted and analyzed comparatively between the SRC and non-SRC groups. The primary objective was to compare the 5-year survival rate between groups.Among 421 patients with a pTis or pT1 tumor, 104 (25%) were SRC and 317 (75%) were non-SRC. Demographic variables were comparable between groups, except median age, which was less in the SRC group (59.6 vs 68.8 years; P.001). Submucosal involvement was more frequent in the SRC group (94% vs 85%; P = .043), whereas lymph node involvement and number of invaded nodes were comparable between the 2 groups. When comparing SRC and non-SRC, recurrence rates (6% vs 9%; P = .223) and sites of recurrence were similar. The 5-year overall survival benefit in SRC patients (85% vs 76%, respectively; P = .035), was not evident when considering exclusively disease-specific survival or in multivariable analysis.Contrary to more advanced GA, SRC morphologic subtype is not a negative prognostic factor in early GA. Better survival identified in some reports may be related to the younger age in SRC patients.

Background In infected incisional ventral hernias (IVHs), the use of a synthetic non-absorbable mesh is not recommended and biological meshes hold promise. However, the level of evidence for their safety and efficacy remains low. Methods The SIMBIOSE trial is a multicenter, phase III, randomized, controlled trial comparing the use of a biological mesh versus traditional wound care in patients with an IVH. The primary end point is 6-month infectious and/or wound morbidity. Secondary end points are wound infection and recurrent hernia rates, post-operative pain, quality of life, time to heal, reoperation need, impact of the cross-linked mesh structure, and a medico-economic evaluation. One hundred patients need to be included. Results The main results expected with biological mesh use are a significant decrease of post-operative morbidity, hernia recurrence, time to heal, and costs with an improved quality of life. Conclusions For the first time, the impact of biological meshes in the treatment of IVHs will be evaluated in an academic, randomized, phase III trial to provide scientific evidence ( NCT01594450). Trial registration ClinicalTrial.gov, NCT01594450

International audience; BACKGROUND: A dramatic increase in the incidence of the diffuse form of gastric adenocarcinomas and particularly signet ring cell carcinomas has been observed in Western countries. Evidence is accruing that signet ring cell carcinomas may have inherent chemo resistance leaving many clinicians unsure of the benefits of delaying surgery to pursue a neoadjuvant approach. METHODS/DESIGN: PRODIGE-19-FFCD1103-ADCI002 is a prospective multicentre controlled randomised phase II/III trial comparing current standard of care of perioperative chemotherapy (2x3 cycles of Epirubicin, cisplatin, 5-fluorouracil) with a strategy of primary surgery followed by adjuvant chemotherapy (6 cycles of Epirubicin, cisplatin, 5-fluorouracil) in patients with a stage IB-III gastric signet ring cell tumour. The principal objective of the phase II study (84 patients) is to determine if the experimental arm (primary surgery followed by adjuvant chemotherapy) has sufficient interest in terms of percentage of living patients at 24 months to be evaluated in a phase III trial. If 7 or less patients in the experimental arm are alive at 24 months, phase III will not be initiated. The primary objective of phase III (230 additional patients) is to demonstrate superiority of the experimental arm in terms of overall survival. Secondary endpoints include overall survival at 36 months, disease free survival at 24 and 36 months, R0 resection rates, treatment tolerance, postoperative mortality and morbidity evaluated by Clavien-Dindo severity index, the prognostic impact of positive peritoneal cytology and the assessment of quality of life. An ancillary study will assess the emotional and cognitive impact of surgery and perioperative chemotherapy for both the patient and their partner. DISCUSSION: As inherent chemo resistance of signet ring cell tumours and delay in definitive surgery may favour tumour progression we hypothesise that a policy of primary surgery followed by adjuvant chemotherapy will improve overall survival compared to a standard perioperative chemotherapeutic strategy. This randomised phase II/III trial is the first dedicated to this histological subtype. Whilst the development of new biomarkers and targeted therapies are awaited, the results of this trial should further help in devising individualised protocols of patient care in a tumour group whose diversity increasingly demands assessment of alternative strategies. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01717924.

The technique of open repair of abdominal aortic aneurysms and aorto-iliac reconstruction has changed little over the past four decades. Endovascular approaches remain under investigation but are limited by anatomical considerations and questions regarding efficacy, safety and durability have not yet been fully answered. Laparoscopic and laparoscopically assisted techniques have been investigated, used alone or in conjunction with a minilaparotomy technique. More recently successful aortic reconstructions using minilaparotomy incisions of 8–10 cm without laparoscopy have been reported. This report describes our preliminary experience with a minimally invasive approach to aortic surgery using a newly developed self-retaining retractor (Ecotracte, Advanced Surgical Concepts, Bray, County Wicklow, Ireland). The retractor (Fig. 1) is composed of two plastic rings joined by a polythene sheet. The inner ring, placed intra-abdominally, is malleable but expands firmly outwards to maintain its circular shape. As this ring is flexible, it may be introduced through a small incision with a lesser circumference. Its flexibility also allows it to be placed precisely around the field of dissection. The outer ring is a more rigid structure, which remains outside the abdominal cavity and also has the added advantage of acting as a wound protector. Once the intra-abdominal ring is in position the plastic sheet is drawn through the outer hoop and stretched backwards over its outer circumference. This draws the walls of the wound and the abdominal viscera outwards and creates an open wound with stable and wide exposure.

Despite a decline in the overall incidence, gastric adenocarcinoma remains the second most common cause of cancer death worldwide and thus a significant global health problem. Even in early-stage locoregional confined disease the 5-year survival rarely exceeds 25–35 %. Randomized trials have demonstrated a benefit from neoadjuvant and perioperative chemotherapy. However the optimal approach in individual patients is not clear and remains controversial. A consistent finding is that patients who have a histopathological response to neoadjuvant therapy are more likely to receive a survival benefit. These clinical data provide a strong argument for the urgent development of methods to predict histopathological response to neoadjuvant therapies for gastric adenocarcinomas. Published data demonstrate that clinico-pathological features (tumour histology and location), imaging through metabolic response by FDG-PET and tissue/molecular biomarkers may all have a predictive value for neoadjuvant therapies. However it is still uncertain from published data whether or not they will be useful for clinical decision making in individual patients. Existing candidate biomarkers need to be properly qualified and validated and novel biomarkers are required and an optimal approach should involve the combination and integration of clinical, imaging, pathological and molecular biomarkers.

Oesophagectomy is one of the most challenging surgical operations. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques decrease morbidity and whether the quality of the oncological resection is compromised. Globally, minimally invasive oesophagectomy (MIO) has been shown to be feasible and safe, with outcomes similar to open oesophagectomy. There are no controlled trials comparing the outcomes of MIO with open techniques, just a few comparative studies and many single institution series from which assessments of the current role of MIO have been made. The reported improvements of MIO include reduced blood loss, shortened time in high dependency care and decreased length of hospital stay. In comparative studies there is no clear reduction in respiratory complications, although larger series suggest that MIO may have a benefit. Although MIO approaches report less lymph node retrieval compared with open extended lymphadenectomy, MIO cancer outcomes are comparable. MIO will be a major component of the future oesophageal surgeons’ armamentarium, but should continue to be carefully assessed. Randomized trials comparing MIO versus open resection in oesophageal cancer are urgently needed: two phase III trials are recruiting, the TIME and the MIRO trials.

Introduction Reviews of the medical school curriculum in the UK and Ireland have recommended the introduction of student-selected components (SSCs). The Department of Surgery in The Royal College of Surgeons in Ireland (RCSI) has introduced a 6-week surgical SSC, which aims to develop practical clinical skills, provide mentorship and prepare students for internship. Methods Emphasis was placed on exposure to surgical specialities, teaching practical skills and student integration into surgical teams. Students completed an online survey pre- and post-SSC, assessing attitudes towards the course and confidence in performing ward-based and surgical skills. Results The mean Likert scale scores increased for all the skills assessed. Students felt that the SSC prepared them for their first day of work and strengthened their desire to pursue surgical careers. Conclusion A surgical SSC has been successful in increasing student confidence in performing practical skills required for commencing work as a doctor. Provision of dedicated SSCs is likely to influence the career choice of students.

gery Study] 4 ), but it is also suggested that this regimen may be responsible for the higher risk of grade 3/4 toxicity and finally for a higher proportion of patients who did not proceed to surgical resection. Even if the therapeutic regimen used in our trial could be responsible for these toxic effects, other factors can also explain the differences observed. The CROSS population had a much higher prevalence of adenocarcinomas, a tumor which is known to have better postoperative outcomes when compared with esophageal squamous cell carcinomas (SCC), in relation with (1) less frequentandlessseverecomorbidities,(2)alowerexposuretoalcoholand tobacco consumption, and (3) a lower risk of malnutrition. In addition, the higher proportion of lower third tumors found in the CROSS trial meant that patients not only received a lower total dose of radiation but also the lung volume spared from radiation was greater. This is a critical point with regards to the development of radiation-induced pneumonitis andsubsequentpostoperativemortality.Eveniftherateofaccrualwaslow in the FFCD trial, related to the relative rarity of patients presenting with early-stage tumors, low case volume per center cannot however be a relevant factor for explaining the higher postoperative mortality rate in the multimodality arm as this figure was only 3.4% in the surgery-only arm with randomization having been stratified by center. Second, regarding efficacy, the 33.3% of pathologic complete response (pCR) is suggested to be low when compared with the SCC population of the CROSS trial. Beside the fact such pCR rate is well within the acceptable range of pCR previously reported, 5 the CROSS trial pCR rate was only 29%, increasing to 49% in the SCC subpopulation that represented only 23% of the overall population. In comparison, SCC represented 70.3% of the overall population in the FFCD trial. Low numbers cannot be used to conclude about the relative efficacy of one regimen over another. Moreover, pCR has not been validated as a reliable surrogate end point in esophageal cancer. We do agree that when considering recurrence, CRT followed by surgery significantly reduced overall and locoregional recurrences in the FFCD trial, as if a subgroup of patients, still to be identified, might benefit from the multimodality regimen. However, any further subgroup analysis of the FFCD database would expose it to multiple testing-related errors, with results more related to chance than scientific relevance. It should be kept in mind that most of the patients died from metastatic disease (70.4% of the recurrence population in the FFCD trial) suggesting that more important than the chemoradiotherapy modalities used, a strategy that will offer a dramatic decrease in the risk of developing metastatic disease is urgently needed. This is not the case with the CROSS regimen, where only a slight decrease of hematogenous recurrences was observed (35% v 29%), the vast majority of patients still experiencing metastatic disease after multimodal treatment (90.5% of the recurrence population). 6 We can hypothetize that the high surgical quality provided in the FFCD 9901 trial, highlighted by the R0 resection rate of 92.1% after surgery alone, when compared with only 69% in the CROSS trial, may be responsible for overcoming the benefits of chemoradiotherapy. This may be specifically true in an early esophageal cancer population where the usual downsizing effect expected from chemoradiotherapy may not influence resection radicality. We believe that before considering the CROSS regimen as the standard of neoadjuvant treatment, several steps should be taken to validate the CROSS results. First, these results should be reproduced in other nonselected populations including earlier tumoral stages, SCC, upper third tumors and patients with poorer performance status. Second, a direct comparison of the FFCD regimen (used worldwide) and CROSS regimen (mainly used in the Netherlands) is needed to better understand which benefits are related to the chemoradiotherapy regimen itself and which benefits are related to patient selection. Such a research program is under investigation in France. All comments issued from comparison of differing populations with differences in perioperative care may be more speculative than scientific.