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OBJECTIVES Several techniques for oesophageal anastomosis during oesophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the notable morbidity of oesophageal fistula, reducing its incidence is of paramount importance. We report our single-centre experience with the semimechanical (SM) technique as compared to a totally manual (TM) technique. METHODS Three hundred and twelve partial and subtotal oesophagectomies performed between January 1998 and April 2018 were analysed. The series was split into a training period (January 1998–September 2015), when both TM and SM techniques were used, and a validation period (October 2015–April 2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding. RESULTS The training period included 212 oesophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction in both leak (0.8% vs 12%; P CONCLUSIONS SM technique for oesophageal anastomosis outperforms TM technique and allows achieving very low complication rates.

Purpose Minimally invasive oesophagectomy is a technically demanding procedure, and the learning curve for this procedure should be explored. A survival analysis should also be performed. Methods A total of 214 consecutive patients who underwent minimally invasive oesophagectomy were retrospectively reviewed. To evaluate the development of thoracoscopic-laparoscopic oesophagectomy and compare mature minimally invasive oesophagectomy and open oesophagectomy, we comprehensively studied the clinical and surgical parameters. The cumulative sum (CUSUM) plot was used to evaluate the learning curve for systemic lymphadenectomy. Cox proportional hazards regression analysis was performed to explore the clinical factors affecting survival. Results The bleeding volume, operation time, and postoperative mortality within 3 months significantly decreased after 20 patients. The rise point for node dissection was visually determined to occur at patient 57 in the CUSUM plots. Patients who underwent mature thoracoscopic-laparoscopic oesophagectomy had better surgical data and short-term benefits than patients who underwent an open procedure. Cox proportional hazards regression analysis showed that the maximum diameter of the tumour cross-sectional area and the number of positive nodes significantly influenced survival. Conclusions The results suggest that thoracoscopic-laparoscopic oesophagectomy has short-term benefits. There was no evidence that it was associated with a significantly better prognosis for patients with oesophageal cancer. ClinicalTrials Gov ID: NCT04217239; January 2, 2020 retrospectively registered.

Introduction Oesophageal surgery recently became centralised in Belgium. This study aims to evaluate surgical outcomes and service delivered one year after implementation of centralisation. Patients and methods All patients undergoing an oesophagectomy between the start of the centralisation; 1st of June 2019 and 31st of May 2020, were included from a prospectively maintained database. Results 53 patients (41 male, 12 female) underwent an oesophagectomy during the study period. Most oesophagectomies were performed through an open left thoracoabdominal approach (64.2%), 30.2% via a minimally invasive approach and hybrid approaches were carried out in 5.7% of patients. In this study population, the 30 day mortality rate was 0% and the 90 day mortality rate was 3.8%, equating to 2 deaths. The overall 30 day readmission rate was 7.5%. Clinically significant anastomotic leaks occurred in 4 patients, (7.5%). Pneumonia and atrial fibrillation were the most frequent complications, both having a prevalence of 32.1%. The median length of stay was 11 days (IQR 9.5-14.5). Conclusion The results from our centre are comparable to those from international registers which demonstrate that centralisation of complex cancer services can be safely implemented.

Adhesions and fibrosis following failed primary surgery for severe gastro-oesophageal reflux (GOR) in neurologically impaired children (NI) can render mobilization of the lower oesophagus and oesophago-jejunal anastomosis a technically demanding exercise both at open surgery and laparoscopy. This paper presents the Modified Oesophago-Gastric Dissociation (M-OGD) as a less complex technical modification of the original Total Oesophago-Gastric Dissociation (TOGD). The stomach is detached from the oesophago-gastric junction with an articulated 5-mm stapler, leaving a 5-mm strip of stomach attached to the oesophagus. An end-to-side isoperistaltic oesophago-jejunostomy is created between the gastric stump and the isoperistaltic jejunal Roux loop. A jejuno-jejunal anastomosis restores bowel continuity. Between May 2018 and February 2020, M-OGD was performed on 3 NI patients with a weight of 9–27.3 kg (median = 14 kg). Median age at surgery was 60 months (18–180), median surgical time 170 min (146–280), median re-feeding time was 3 days (2–5), and median length of stay was 20 days (11–25). All patients healed primarily and after a median follow-up of 3 months, there were no problems related to the oesophago-jejunal anastomosis. M-OGD reduces the difficulties of redo oesophageal surgery following failed anti-reflux procedures, with a safer oesophago-jejunal anastomosis and a good long-term outcome.

Background/purpose: Irreproducibility and missing translatability are major drawbacks in experimental animal studies. Hand-sewn anastomoses in oesophageal surgery are usually continuous, whereas th...

A considerable number of reports have been published on the feasibility, techniques, and early postoperative results of robotic-assisted oesophageal surgery. However, these are mostly smaller case series, suggesting that the robot-assisted Ivor Lewis procedure is still in the implementation phase and far from being standardised. Oesophageal surgeons from seven robotic university centres in Germany, experienced in both minimally invasive and robot-assisted minimally invasive surgery, took part in a workshop on robot-assisted surgery. An intensive exchange of opinions and experiences, followed by a step-by-step re-enactment of the operation in a cadaver lab, enabled us to develop a standardised robot-assisted Ivor Lewis surgical workflow, which is presented here. Systematic and objective comparison of experiences and results using a robot-assisted Ivor Lewis procedure has made it possible to develop a standardised surgical workflow that is now clinically applied in our centres. It is hoped that standardisation of this procedure will help to maintain patient safety, prevent medical errors, and facilitate the learning curve, while introducing robotic surgery into a centre.

The aim of this paper was to review the entire literature on esophageal surgery to best define the surgical indications and the specifics of their management. The bibliographic research was carried out on Pubmed between January 1995 and June 2015, using French and English as publication languages.

Introduction: Post-prandial hyperinsulinaemic hypoglycaemia (PPHH) is a recognized complication of various gastric surgeries in children, but rarely reported after oesophageal atresia repair. We report 2 children diagnosed with PPHH after oesophageal surgery and the challenges of their management. Case 1: A 2-year-old boy diagnosed with oesophageal atresia at birth was surgically repaired requiring 6 oesophageal dilatations in the first year of life. At 11 months of age, he manifested hypoglycaemic seizures and investigations confirmed PPHH. Acarbose and diazoxide trials failed. He was managed with 17-h continuous gastrostomy feeds. Currently, he is 28 months old with euglycaemia on daytime bolus gastrostomy feeds and overnight 12-h continuous gastrostomy feeds. Case 2: A 6-month-old girl diagnosed with Wolf-Hirschhorn syndrome and tracheo-oesophageal fistula was surgically repaired, requiring monthly oesophageal dilatations. At 5 months of age, she was reported to have hypoglycaemia and PPHH was confirmed. She responded to diazoxide and continuous nasogastric tube feeds, but developed pulmonary hypertension pos­sibly diazoxide-induced. Subsequently, diazoxide was stopped and normoglycaemia was secured via 20-h continuous gastrostomy feeds. Conclusion: PPHH may be an underdiagnosed complication in children undergoing surgery for oesophageal atresia. These children must be monitored closely for symptoms of hypoglycaemia and if there are concerns must be screened for possible PPHH. Our cases demonstrate that continuous feeding regimens might be the only therapeutic option, until PPHH gradually lessens in intensity over time.

Purpose: Follow-up practices for patients who have undergone surgical resection of esophagogastric malignancies are variable and poorly documented. To better understand practice, a questionnaire was used to survey surgeons and medical oncologists to determine whether any consensus exists. Methods: An opt-in online questionnaire was sent to esophagogastric surgeons and medical oncologists via the membership lists for the Australian and New Zealand Gastric and Oesophageal Surgery Association (ANZGOSA), the Australian Gastro- Intestinal Trials Groups (AGITG), and the Medical Oncology Group of Australia (MOGA). The questionnaire proposed five clinical scenarios and provided a range of follow-up options for each scenario. Clinicians were asked to indicate which best matched their clinical practice. Results: Most clinicians follow patients for at least 3–5 years following resection of gastric or esophageal cancer. In total, 52% perform routine surveillance imaging, with individual scenarios not altering this. Tumor markers are infrequently used. Endoscopy and routine blood tests are used by around half the respondents. Conclusion: There was little consensus about the use of investigations to monitor patients following esophagogastric cancer surgery. Choices do not follow guidelines or evidence. The identified patterns of postoperative surveillance practice appear not to be evidence based, and generally do not match recently published Australian guidelines.

Oesophageal surgery is performed infrequently in dogs and cats, although there are a number of well defined indications. This chapter covers functional anatomy, surgical approaches and principles, indications for oesophageal surgery, oesophageal foreign bodies, oesophageal stricture, and intra- and postoperative management of oesophageal surgical cases.

Hintergrund: Die abdominothorakale Osophagusresektion nach Ivor Lewis zahlt zu den komplexen viszeralchirurgischen Eingriffen. In den letzten Jahren wurden zunehmend Teilschritte in minimalinvasiver Technik durchgefuhrt, jedoch ist insbesondere die intrathorakale Anastomose bei dem heutigen Stand der apparativen und technischen Mittel nach wie vor eine Herausforderung. Wir berichten detailliert uber den Einsatz des Da Vinci-Robotersystems und unsere Technik bei der Osophaguschirurgie. Material und Methoden: In einer prospektiven Datensammlung erfolgte die Auswertung der im Universitatsklinikum Schleswig-Holstein, Campus Kiel, im Zeitraum von November 2013 bis November 2015 durchgefuhrten roboterassistierten Osophagusoperationen. Ergebnisse: Insgesamt 56 Patienten unterzogen sich einer roboterassistierten Operation an der Speiserohre, wobei 43 Ivor-Lewis-, 10 McKeown-Prozeduren bei Karzinomen sowie 3 Enukleationen von Leiomyomen durchgefuhrt wurden. Bei 53 (93,4 %) der Patienten konnte ein R0-Resektionsstatus erreicht werden, die mittlere Lymphknotenausbeute betrug 23 (14–75). 45 der Patienten (80,5 %) wurden neoadjuvant vorbehandelt. Die mittlere OP-Zeit betrug 412 min (120–610). Eine Konversion auf ein offenes Verfahren war bei 19 (34,1 %) notwendig, wobei dies uberwiegend (17 Patienten) im thorakalen Teil der Operation notwendig war. Bei 43 Patienten wurde eine intrathorakale Osophagogastrostomie angelegt; bei der initial angelegten Seit-zu-Seit-Osophagogastrostomie entwickelten 4 von 5 Patienten eine Leckage, sodass die Technik auf ein handgenahtes Verfahren umgestellt wurde (Leckage bei 3 von 20 Patienten). Andere Majorkomplikationen waren eine Leckage im Magenschlauch bei 2 (3,6 %), eine bronchotracheale Fistel bei 2 (3,6 %), mesenteriale Ischamie bei 1 (1,8 %), Peritonitis durch dislozierte Ernahrungssonde bei 1 (1,8 %), pulmonale Komplikationen bei 19 (34 %) der Patienten. Vier (7,1 %) der Patienten verstarben postoperativ aufgrund einer Lungenarterienembolie, eines Myokardinfarkts sowie eines septischen Kreislaufversagens. Schlussfolgerung: Die roboterassistierte minimalinvasive Osophagusresektion kann technisch und onkologisch sinnvoll angewandt werden. Die Einfuhrung dieser Technik sollte in einem strukturierten Programm mit einer kritischen und intensiven Evaluation eigener Ergebnisse und einem Austausch mit anderen Gruppen erfolgen. Dadurch konnen „Pitfalls“ vermieden werden und eine schnellere Lernkurve erreicht werden. Weitere technische Entwicklungen und Erfahrungen konnten dazu fuhren, dass diese Technik zunehmende Anwendung findet.

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Background Enhanced recovery programmes improve outcomes in surgery, but their implementation after upper gastrointestinal resection has been limited. The aim of this study was to compare short-term outcomes for patients undergoing oesophagogastric surgery in an enhanced recovery programme (EROS). Methods EROS was developed after a multidisciplinary meeting by multiple rounds of revision. EROS was applied to all patients undergoing major upper GI resection at a university teaching hospital in the UK from 20/9/13, with data reviewed at 18/09/15. EROS was assessed to identify predictors for compliance. Results One hundred six patients underwent major upper GI resection including 81 oesophagectomies, 24 gastrectomies and 1 colonic interposition graft. Major complications (Clavien Dindo ≥3) occurred in 12 patients with 1 in-hospital death. Thirty-five patients (44%) were discharged on target day 8 of the EROS programme. Age and complications were independently associated with missing this discharge target. Conclusion Enhanced recovery is feasible and safe after major upper gastrointestinal surgery. Electronic supplementary material The online version of this article (doi:10.1007/s11605-017-3363-8) contains supplementary material, which is available to authorized users.

OBJECTIVE To update the recommendations for the structural characteristics of general thoracic surgery (GTS) in Europe in order to provide a document that can be used as a guide for harmonizing the general thoracic surgical practice in Europe. METHODS A task force was created to set the structural, procedural and qualification characteristics of a European GTS unit. These criteria were endorsed by the Executive Committee of the European Society of Thoracic Surgeons and by the Thoracic Domain of the European Association for Cardio-Thoracic Surgery and were validated by the European Board of Thoracic Surgery at European Union of Medical Specialists. RESULTS Criteria regarding definition and scope of GTS, structure and qualification of GTS unit, training and education and recommendations for subjects of particular interest (lung transplant, oesophageal surgery, minimally invasive thoracic surgery, quality surveillance) were developed. CONCLUSIONS This document will hopefully represent the first step of a process of revision of the modern thoracic surgeons' curricula, which need to be qualitatively rethought in the setting of the qualification process. The structural criteria highlighted in the present document are meant to help and tackle the challenge of cultural and language barriers as well as of widely varying national training programmes

Iatrogenic tracheobronchial injury is rare. Limited data is available on such injuries in infants and management of these is challenging. We present a 7-month-old male infant who was diagnosed with oesophageal stricture, and was planned for thoracoscopic repair of the same. Anaesthetic management with a single lumen tracheal tube ensued. However, an intraoperative loss of capnogram and desaturation led to the diagnosis of iatrogenic tracheobronchial injury. After unsuccessful pursuits with a Fogarty catheter through the tracheobronchial tear and through the right bronchus for lung isolation, blind left endobronchial intubation with a smaller tube and one lung ventilation was successful. The rent was repaired by an open procedure, and oesophageal surgery completed. However, the child succumbed and died of multiorgan failure 3 days later.

Conduit necrosis is a rare but potentially devastating complication of oesophageal surgery and the subsequent reversal of oesophageal discontinuity can be challenging. An option for both cervical-oesophageal reconstruction and neck wound closure has been limited and less successful. We report a patient with colon conduit necrosis and cervical-oesophageal discontinuity whose cervial oesophagus was successfully reconstructed with a single-stage pedicled pectoralis major myocutaneous flap and neck wound closure.

Introduction Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls. Methods Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed. Results A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06–12.33, pConclusions Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.

Pleural infection is a common clinical problem that is associated with a high mortality and morbidity. In the UK, the mortality is 20% with 20% requiring surgery. The development of an empyema associated with pneumonia is a progressive process classified in three stages. Initially, there is a free-flowing exudate with a normal pH termed a simple parapneumonic effusion. This progresses to a fibrinopurulent stage with increasing fluid and bacterial invasion causing a decrease in pH. If the fluid is clear but the pH ,7.2, this is termed a complicated parapneumonic effusion while frank pus is termed an empyema. The third stage is an organizing stage with the formation of a solid fibrous peel. Pleural infection can also occur after pleural interventions, thoracic or oesophageal surgery, trauma, or oesophageal rupture.

Several studies have proven an ameliorated prognosis after a neoadjuvant therapy for locally advanced Barrett's carcinoma in case of response. The necessary amount of neoadjuvant chemotherapy within a multimodal therapy concept with following oesophageal resection has never been evaluated so far.The clinical course of 122 patients with Barrett's carcinoma, who all underwent a neoadjuvant chemotherapy with cisplatin, five fluorouracil and leucovorin and following oesophagectomy, was reviewed. The pretherapeutic clinical and postoperative histopathological staging, histopathological response, clinical course, recurrence rates and long-term survival were retrospectively analysed and compared to the data of 30 patients, who were included in the same multimodal therapy concept, but who had to cease the chemotherapy early because of toxicity.Postoperative pathological staging showed that the response rate correlates with the N and R status. The responding patients benefit from longer survival. Comparing the two subgroups, we could not find a significant difference in response rate, tumour staging, resection rate, long-term survival or pattern of recurrent disease. However, postoperative morbidity and mortality did not correlate with severe chemotherapy-induced toxicity.This is the first study on the necessary number of chemotherapy cycles in terms of a neoadjuvant therapy for Barrett's carcinoma. We could show a similar downstaging effect, a good histopathological response and a comparable ameliorated long-term survival of patients with one compared to patients with three chemotherapy cycles. A biological selection seems to determine the course of the disease already at this early stage.

BACKGROUND: Prevention, early recognition and an adequate management of perioperative complications in resectional oesophageal surgery are the keys to an increased safety of these complex procedures. RECOGNITION, DIAGNOSTICS, MANAGEMENT AND TREATMENT: Preoperative registration and – if re-quired – pretreatment of specific risk factors can consid-erably decrease the complication rate. The precise implementation of significant preoperative score systems in patients with high operative risk can lead to a negative risk-benefit consideration concerning the indication for an operation. The patients will then be assigned to an alternative treatment process. Anastomotic leakage is the most frequent technical-surgical complication. A precise suturing technique with the prevention of tension and the avoidance of reduction of -perfusion of the conduit (stomach, colon, small intestine) can reduce the rate of such insufficiencies. The most frequent non-surgical complica-tion is postoperative pneumonia, which can be avoided or combated through effective pain-re-liev-ing ther-apy like peridural anaesthesia and specific techniques of postoperative ventilation. It is of vital importance to identify, at the earliest possible timepoint, complications that might emerge after the operation. The occurrence of postoperative tachyarrhythmia has proven to be a frequent and early indicator of such compli-cations. The treatment of complications after oesoph-a-geal resections includes adequate conservative, interventional, e. g., endoscopic placement of a stent in cases of covered insufficiency of the suture line, and operative procedures like re-oper-ation in cases of uncovered leakage with pleural connection. All the other surgical complications like haemorrhage, tracheobronchial leak-ages or chylothorax are rarely seen and demand specific therapeutic procedures. CONCLUSION: It is not only the surgery that determines a high or low complication rate in oesophageal resectional procedures. It has clearly been proved that interdisciplinary management of complications after oesophagectomy is much more effective in high-volume centres, leading to a lower mortality, than in sur-gical departments with a lower case rate and thus with less -ex-perience in such complex operations.

Introduction Competency in complex oesophagogastric surgery, within the current climate of changes to medical training and reduced hours, requires repeated, focused, hands-on training. We describe the training methods for oesophagectomy in our institution. Methods All oesophageal resections under the care of one consultant surgeon are regarded as training cases. When trainees start they are shown the first resection; subsequently, the trainees then perform every case with the consultant scrubbed. Consultant input consists of retraction and tips in difficult situations. All data were collected on a prospective database. Results Two hundered and seventy patients (215 males, median age=64 years) underwent primary oesophagectomy under the consultant, between January 2000 and May 2007. Fifteen resections (6%) were performed solely by the consultant. ASA grading was: I=15, II=154, III=95, IV=5, and unrecorded=1. In-hospital mortality and clinically apparent leak rate was 1.9% (5 deaths) and 6.2% ( n =17), respectively. Reoperation was required in 15 patients (5.5%). The median length of hospital stay was 14 days (range=8–95 days). Median lymph node yield was 13 (range=0–64). Conclusions Trainees under supervision can competently perform an oesophagectomy without compromising patient care. An early hands-on approach leads to a rapid ascent of the learning curve and is essential in today's climate of limited training opportunity.

BACKGROUND Consequences of the volume outcome relationship are controversial. Objectification based on data analysis is strongly needed. The aim of this publication was to analyse the effects of volume outcome reallocations based on German inpatient data. METHOD The analysis based on inpatient data of the Krankenhauszweckverband Koeln, Bonn und Region (Hospital Association of the Cologne and Bonn Region) of 2002 and 2005. Relevant data sets were identified according to the effects of current German regulations on volume outcome on the special fields liver transplant, kidney transplant, complex pancreatic surgery, and complex oesophageal surgery. RESULTS The effects of current German regulations on volume outcome results differed greatly between the four surgical specialities. There were fewer effects on kidney transplant, but due to an already very high level of centralisation 34% (oesophagus) and 8% (pancreas) of the hospitals stopped related surgery. This affected 8.9% (oesophagus) and 2.2% (pancreas) of related cases. CONCLUSION Concentration and the formation of specialised medical centres are results of the implementation of volume outcome relationships. The quality of medical treatment does not automatically improve from this development. It is necessary to analyse any correlation between quality and frequency of treatment or other criteria such as know-how, structure and process management, and multidisciplinarity.

Benign oesophageal strictures may occur as a complication of caustic ingestion or severe gastro-oesophageal reflux or as a sequela of oesophageal surgery and other fibrosing conditions. The traditional initial treatment of oesophageal strictures is intraluminal dilation; however, even if frequent, this occasionally may not provide adequate oesophageal lumen capacity or give significant symptom-free intervals, and restricturing after dilation is difficult and challenging. Topical postdilation application of an antifibrotic agent, mitomycin-C, in the treatment of an oesophageal stricture has been described.Eight centres participated, with a total of 16 patients (4 girls), median age 48 (range 0-276) months. The causes of stricture were as follows: caustic (10), post-trachea-oesophageal fistula repair (2), peptic (2), Crohn disease (1), and dystrophic epidermolysis bullosa (1). The median (range) length and diameter of the strictures were as follows: 22 mm (8-50 mm) and 1.5 mm (1-6 mm). Of the 16 patients, 15 had undergone repeated dilations varying from 3 to more than 1000 (daily self-bouginage) before mitomycin-C, and the median interval between dilations was 4 weeks. Mitomycin-C 0.1 mg/mL was applied after dilation for a median time of 3.5 minutes and a median of 3 (1-12) times.Major success, both endoscopic and clinical improvement or cure, occurred in 10 of 16 patients. In 3 of 16 patients the interval period between dilations increased dramatically. Failure of therapy was considered in 3 of 16. All of the patients remained symptom free for a follow-up time of as long as 5 years.Postdilation application of topical mitomycin-C resulted in major success in 62.5% of patients and partial success in 19%, and it may be a useful strategy in oesophageal strictures of differing causes that are refractory to repeated perendoscopic dilation.

Even as the preferred treatment of achalasia migrates towards per-oral endoscopic myotomy (POEM), the relative merits of pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) continue to be argued. In this issue of Gut , the long-term results of the European achalasia trial comparing 201 patients randomised to PD or LHM are presented,1 reporting similar outcomes between therapies. After a minimum follow-up of 5 years, 82% of patients with PD and 84% of patients with LHM had a sustained good response when analysed by intention to treat (or 91% of patients with PD and 82% of patients with LHM when analysed per protocol). The outcomes being similar, the authors conclude that the decision between therapies should be based on available expertise and patient preference. Certainly, this was an important trial and an important result. Equally certain, the medical-surgical debate will continue. Assessing the adequacy of treatment in achalasia has many facets. There are many ways to look at it and, most assuredly, surgeons and gastroenterologists will not look at these data the same way. The ideal therapy for achalasia would revert swallow function to normal, render the patient symptom-free and not result in pathological reflux. No current therapy achieves this and none on the horizon is likely to do so. …

Objective: The diagnosis and management of oesophageal perforation continues to challenge clinicians. We present our experience of perforated oesophagus in a Tertiary Referral Centre for Thoracic and Oesophageal Surgery. Methods: Between 1985 and 2000, 75 patients (40 male) with oesophageal perforation were treated in out unit; age range 24– 89, median 63. Retrospective review of these cases has been performed. Results: There were 12 deaths (16%). With increases in time from perforation to diagnosis, there was a stepwise increase in the mortality rate. Immediate diagnosis 5%; early diagnosis (1 – 24 h) 14%; late diagnosis (.24 h) 44% ðP $ 0:002Þ. Site of perforation, aetiology, and treatment strategy had no influence on mortality. The only independent predictor of mortality identified was time to diagnosis from perforation (beta 0.429, P ¼ 0:001Þ. Time to definitive management in those undergoing an operative procedure had no influence on outcome with multivariate analysis. Conclusions: Prompt recognition of the diagnosis of oesophageal perforation and rapid institution of supportive measures, followed by an appropriate, patient specific treatment option optimises the chance of a successful outcome. The wide range of presentation of oesophageal perforation necessitates individualisation of treatment. q 2003 Published by Elsevier Science B.V.

OBJECTIVES Evaluation of complex, acquired, non-malignant tracheo/broncho-oesophageal fistulas (TEF) repaired by extrathoracic pedicled muscle flaps that were, in addition to their interposition between the airways and the gastro-intestinal tract, patched into gastro-intestinal or airway defects if primary closure seemed risky. METHODS A single institution experience of patients treated between 2003 and 2015. Twenty-two patients required TEF repair following oesophageal surgery (18), Boerhaave syndrome (1), chemotherapy for mediastinal lymphoma (1), carinal resection and irradiation (1) and laryngectomy (1); 64% of them underwent prior radio- or chemotherapy and 50% prior airway or oesophageal stenting. RESULTS Airway defects were closed by muscle flap patch ( n = 12), lobectomy ( n = 4), airway resection/anastomosis ( n = 2), pneumonectomy ( n = 1), segmentectomy ( n = 2) or primary suture ( n = 1). Gastro-intestinal defects were repaired by oesophageal diversion ( n = 9), muscle flap patch ( n = 8) or primary suture ( n = 5). A muscle flap patch was used to close airway and gastro-intestinal defects in 55% and 36% of cases, respectively. The 90-day postoperative mortality and TEF recurrence rates were 18% and 4.5%. Airway healing and breathing without tracheal appliance was obtained in 95% of patients and gastro-intestinal healing in 77% of those without oesophageal diversion. Five of nine patients with oesophageal diversion underwent intestinal restoration by retrosternal colon transplants. CONCLUSIONS Complex TEF arising after oesophageal surgery, radio-chemotherapy or failed stenting can be successfully closed using extrathoracic muscle flaps that can, in addition to their interposition between the airway and the gastro-intestinal tract, also be patched into gastro-oesophageal or airway defects if primary closure seems hazardous.

A rare anatomic variant of the right vertebral artery is reported as an incidental finding in a 78-year-old female patient. The vessel originated from the aortic arch distal to the origin of the left subclavian artery and presented an unusual retroesophageal course, thus was named "vertebral arteria lusoria". As multi-detector row computed tomography examination is now widely used, this anatomical variant should be considered in any patient undergoing esophageal surgery. Misdiagnosis of such an aberrant vertebral artery may cause life-threatening issues.

Worldwide an increasing part of oncologic oesophagectomies is performed in a minimally invasive way. Over the past decades multiple reports have addressed the perioperative outcomes and oncologic safety of minimally invasive oesophageal surgery. Although many of these (retrospective) case-control studies identified minimally invasive oesophagectomy as a safe alternative to open techniques, the clear benefit remained subject to debate. Recently, this controversy has partially resolved due to the results of the first randomized controlled trial that compared both techniques. In this trial short-term benefits of minimally invasive oesophagectomy were demonstrated in terms of lower incidence of pulmonary infections, shorter hospital stay and better postoperative quality of life. However, the current lack of long-term data on recurrence rate and overall survival precludes a comprehensive comparison of minimally invasive and open oesophagectomy. Proclaiming minimally invasive oesophagectomy as the standard of care for patients with resectable oesophageal cancer would therefore be a premature decision.

Pulmonary complications are frequently observed after transthoracic oesophagectomy. These complications may be reduced by sparing the vagus nerve branches to the lung. However, current descriptions of the regional anatomy are insufficient. Therefore, we aimed to provide a highly detailed description of the course of the pulmonary vagus nerve branches. In six fixed adult human cadavers, bilateral microscopic dissection of the vagus nerve branches to the lungs was performed. The level of branching and the number, calibre and distribution of nerve branches were described. Nerve fibres were identified using neurofilament immunohistochemistry, and the nerve calibre was measured using computerized image analysis. Both lungs were supplied by a predominant posterior and a smaller anterior nerve plexus. The right lung was supplied by 13 (10-18) posterior and 3 (2-3) anterior branches containing 77% (62-100%) and 23% (0-38%) of the lung nerve supply, respectively. The left lung was supplied by a median of 12 (8-13) posterior and 3 (2-4) anterior branches containing 74% (60-84%) and 26% (16-40%) of the left lung nerve supply, respectively. During transthoracic oesophagectomy with en bloc lymphadenectomy and transection of the vagus nerves at the level of the azygos vein, 68-100% of the right lung nerve supply and 86-100% of the inferior left lung lobe nerve supply were severed. When vagotomy was performed distally to the last large pulmonary branch, 0-8% and 0-13% of the nerve branches to the right middle/inferior lobes and left inferior lobe, respectively, were lost. In conclusion, this study provides a detailed description of the extensive pulmonary nerve supply provided by the vagus nerves. During oesophagectomy, extensive mediastinal lymphadenectomy denervates the lung to a great extent; however, this can be prevented by performing the vagotomy distal to the caudalmost large pulmonary branch. Further research is required to determine the feasibility of sparing the pulmonary vagus nerve branches without compromising the completeness of lymphadenectomy.

Oesophageal sarcoma is a potential sequel of Spirocerca lupi infection. Oesophageal mass excision can be performed by open chest surgery. The objectives of this observational study were to evaluate the feasibility, short-term morbidity and long-term outcome of transendoscopic oesophageal mass ablation in dogs with spirocercosis-associated oesophageal neoplasia. A 9 mm video-endoscope and laser or electrocauterisation were used to debulk the oesophageal mass. Long-term follow-up was done by telephonic interviews. Fifteen dogs were included. The median tumour size was 5 cm (range 3.5-9). The median procedure time was 75 minutes (range 35-165) and was deemed successful in 12/15 dogs (80 per cent). Recovery was uneventful in all dogs. Immediate complications included oesophageal damage (two dogs) oesophageal perforation (one dog) and a focal thermal damage (one dog). The median hospitalisation time of all dogs was less than one day, with all but two discharged on the procedure day. The median survival time, available in nine dogs that were followed, was 202 days (range 51-691). Four of these dogs (44 per cent) survived more than six months, of which three survived more than one year. In conclusion, transendoscopic oesophageal mass ablation might be considered an alternative, palliative procedure for open-chest oesophageal surgery. It has comparable long-term survival, lower morbidity, short hospitalisation time and relatively low cost.

Laparoscopic surgical procedures involving the gastro-oesophageal region are commonly performed for the management of morbid obesity and refractory gastro-oesophageal reflux disease (GORD). In general, laparoscopic procedures are associated with lower morbidity and mortality in comparison with open techniques. This report highlights cases of potentially life threatening, late onset pericardial tamponade, occurring in the absence of infection or trauma, complicating laparoscopic gastro-oesophageal surgery. Possible mechanisms, clinical manifestations, diagnostic investigations and management of pericardial tamponade are reviewed.

Summary Bronchoscopy was performed in 161 patients with oesophageal atresia or tracheo-oesophageal fistula without atresia between 1983 and 1991 at The Children's Hospital, Cologne, Germany. Twelve patients had oesophageal atresia without fistula, and seven patients had tracheo-oesophageal fistula without atresia. In the 149 patients with congenital tracheo-oesophageal fistula a total of 154 fistulae were found. In the five patients with two fistulae the second was detected in one patient only during primary anastomosis, and in the other four patients by bronchoscopy up to 18 years after the original operation. The study group comprised 113 newborn infants and 48 patients admitted for evaluation of severe airway problems. A very high proportion (89%) of the newborn infants had an associated abnormality of the respiratory tract. In the other 48 patients, all showed a tracheobronchial abnormality. Fourteen of these patients required tracheal surgery and 12 improved following oesophageal surgery. A comparison between the incidence of the types of oesophageal atresia previously described and this series showed a marked difference, which is probably due to greater precision of the location of the fistula demonstrated by bronchoscopy. Bronchoscopy should be undertaken in all patients with oesophageal atresia with a tracheo-oesophageal fistula.

Surgical resection of oesophageal cancer still offers the only chance of cure for this disease. Nevertheless, oesophageal surgery may be accompanied by relevant mortality and morbidity, the causes of which can be both directly related to surgical technique as well as a large spectrum of non-surgical complications. In the last few years, improvements in patient selection and technical advances, as well as elaborated peri- and post-operative management, have helped to reduce these threats.The following article adresses important aspects of patient selection and evaluation, pre-operative preparation, anaesthesia, operative prohylaxis of complications, immediate post-operative care and complication management. All these factors are important contribiutions to improve the outcome in this challenging medical condition. Nowadays, experienced centres report operative mortality rates of around 5% for radical transthoracic resections (Low et al. 2007; Or­ringer et al. 2007; Ando et al. 2000; Karl et al. 2000; Whooley et al. 2003), down from rates of up to 30 or 40% in previous decades (Earlam and Cunha-Melo 1980). Many factors have contributed to these improvements; some authors claim large volume centres have a tendency to improve results, mostly due to more aggressive management of post-operative complications (Forshaw et al. 2006; van Lanschot et al. 2001; Smith et al. 2008). The following article summarizes the factors that have been identified in the past decades to influence the outcome of major surgery for the resection of adenocarcinoma of the oesophagus.

Introduction Multiple groups have previously reported the influence of BMI on outcomes following oesopheageal surgery but their conclusions have been limited by a lack of clear delineation of patient characteristics as well as geographical location and the nature of multimodal treatment. In order to address the specific question concerning the impact of preoperative BMI on western patients’ outcomes after oesophageal cancer surgery we have performed a meta-analysis, taking into account histology characteristics wherever possible. Method Between December 2014 and January 2015 a comprehensive electronic search was performed to identify Western publications relating to BMI and outcomes after oesophagectomy. Articles that did not report preoperative BMI, morbidity, early mortality and 5 years overall survival were excluded. The search was performed using Pubmed and the reference lists for each of the articles included was also reviewed in order to find any additional studies. Statistical analyses were performed using OpenMetaAnalyst software (Version 10.10). Results 161 records were examined, 9 western studies were included with a total of 3150 pts of which 317 were specifically affected by adenocarcinoma. The study population was stratified into 2 groups: normal group (BMI 30). Whilst higher BMI was associated with a greater risk for anastomotic leaks (near 25% with a p-value of 0.102), bleeding (18% and 0.213), wound infections (25% and 0.090) and poorer long term survival (near 20% and 0.090) this was not found to be statistically significant. Cardiac, pulmonary and any major complications were not significantly different between the 2 groups. On the other hand, there was a 20% greater risk for early postoperative mortality in the normal BMI group although the difference did not reach statistical significance as well as recurrent laryngeal nerve injury. Normal BMI was also significantly associated with chyle leaks (0.021). Stratification according to histology was possible in the analysis of 3 postoperative complications (anastomotic leakages, pulmonary events and early mortality). In the adenocarcinoma group High BMI was significantly associated with pulmonary complications (0.009). Conclusion This meta-analysis shows that in Western studies BMI above 30 is not associated with increased mortality or morbidity after oesophageal surgery, although there is an increase in pulmonary complications of those who have adenocarcinoma. BMI These results suggest that BMI should not exclude patients from being treated with curative intent in multimodal treatment; however the increased risk of pulmonary complications should trigger careful preoperative respiratory assessment and optimisation. Disclosure of interest None Declared.

Mediastinitis is a life-threatening complication of cardiac, neck and oesophageal surgery. It has also been reported following upper digestive and respiratory procedures and as a consequence of oesophageal perforation following the ingestion of foreign bodies. Much more infrequently, mediastinitis can occur in association with oropharyngeal or cervical infections. We describe the case of a patient with fatal mediastinitis and septic shock. The onset of mediastinitis was preceded by a 2-day course of sore throat and other flu-like symptoms.

We thank Dr Thakkar and colleagues [1] for their interest in our article [2]. The choice of oesophageal reconstruction route, generally between the anterior (AR) and the posterior mediastinal route (PR), is not only the first decision for the surgeons to make after oesophagectomy, but also a long-lasting controversy in oesophageal surgery. In our experience, there are three major aspects to be taken into consideration: the first is the long-term effect on the patients and the purpose of the surgery; the second is the surgeon’s preference and proficiency; and the third is the perioperative morbidity and mortality. For the first consideration, the difference in survival between patients who have undergone AR and PR has never been reported in any randomized clinical trial (RCT). However, there is no doubt that the application of AR provides patients with extra benefits on admission for postoperative irradiation of the tumour bed and avoids infiltration by locally recurrent tumour, which is important for subsequent treatment and survival. The surgeon’s preference and proficiency is a factor that is hard to depict and control but necessarily important for the effect of the treatment. It is commonly accepted that a shorter route can facilitate the reconstruction procedure, which could be a factor in the ‘first choice’. We have demonstrated both in patients intraoperatively [3] and in cadavers [2] that the AR is a shorter choice for the gastric conduit to reach the cervical anastomosis, and this conclusion could provide a sound anatomical basis for surgeons to make their decisions. Considering the perioperative morbidity and mortality, we agree with Dr Thakkar and colleagues that current data are still insufficient to declare the superiority of either route. Taking leakage of the cervical anastomosis as an example, a meta-analysis [4] based on four RCTs and an additional RCT [5] mainly applying a transhiatal oesophagectomy or a minimal invasive oesophagectomy procedure reported that their leakage incidence in the AR group ranged from 7.1 to 32.5%, but this was not significantly higher than in the PR group according to the meta-analysis (relative risk 1.01, 95% confidence interval 0.35–2.94; P = 0.98). While experience from retrospective studies, most of which concerned transthoracic oesophagectomy, suggested an unacceptably higher leakage incidence using the AR approach. Besides their possibly palliative use of the AR approach, it occurred to us that the details of the oesophageal reconstruction via AR should be addressed to extend patients’ advantage. In one of our recent comparative studies [6], we made several modifications to the reconstruction via AR after a three-incision oesophagectomy, which included expanding the retrosternal tunnel, widening the gastric tube, resection of the sternothyroid muscle and fixation of the gastric tube, which we termed Chen’s procedure. As a result, patients received improved AR reconstruction had a significantly lower incidence of leakage of the anastomosis compared with patients who received a routine AR reconstruction without modifications (4.84 vs. 20%; P = 0.037). It is hard to say whether there is a ‘best surgery’ for oesophageal cancer, but we are extending our research in order to provide more convincing results, and we look forward to further RCTs in order to provide evidence-based and individualized treatment of patients.

Controlled trials have not established that stapled anastomoses are either better or worse than manually sutured anastomoses. Such trials, however, have usually been performed in units expert in the techniques of oesophageal surgery. It seems quite likely that in the hands of less expert surgeons the stapled anastomosis is safer, because the anastomosis is standardized and it probably has a better blood supply than a manually constructed anastomosis.

We read with big interest the paper by Swanstrom et al. in which authors described the use of a flexible endoscope in oesophageal surgery through a cervical incision. Swanstrom et al. demonstrated here the feasibility of oesophageal mobilisation and dissection in a para-oesophageal plane using a flexible endoscope through a small cervical incision. Authors emphasised the inescapable help provided by positive pressure CO2 mediastinoscopy in the creation and dissection of tissue planes in the mediastinum. They also mentioned a severe cardiopulmonary derangement in one animal due to mediastinum high pressure. The para-oesophageal plan is located in the same anatomical space than the para-tracheal plane which is bordered by the mediastinal pleura. The creation of a communication between the para-tracheal space and the pleural cavity through the mediastinal pleura (pleurotomy) offers a good access to pleural cavities through a cervical incision. Our questions to doctor Swanstrom are the following: before the step of oesophageal dissection using gas inflation, do you think that the creation of a communication between the latero-tracheal space and the pleura using classical mediastinoscopic instruments, which did not necessitate any gas inflation, could offer a better control of the mediastinal inflation pressure during the following oesophageal dissection? And do you think that this communication helped by a simple intercostal needle to evacuate supplementary pressure could diminish the cardiopulmonary derangement due to mediastinal inflation? The creation of a communication between the mediastinum and pleural cavity through a cervical incision has already been described using classical thoracoscopic tools. Unfortunately, the rigidity of classical instruments did not allow a large exploration of the pleural cavity. Using flexible endoscope property through validated and classical cervical access (mediastinoscopy) seems to be more adapted for thoracic specificities and could avoid major mediastinal complications than in N.O.T.E.S. approaches. In addition, it could afford large applications in the pleural cavity through single cervical incision. More experimental studies are needed to assess the role of flexible endoscope in the exploration of the mediastinum and pleura through a cervical incision using a flexible endoscope.

The growth and scope of laparoscopic gastrointestinal surgery are outstripping the ability of medical journals to print series and reports of experience, and much data remain anectodal and preliminary. Laparoscopic cholecystectomy has become established, although, unfortunately, peroperative cholangiography has not yet become normal practice, despite convincing published evidence that it is likely to reduce the increased number of bile ducts that are damaged by laparoscopic surgeons. Imaging the bile ducts and the overall management of choledocholithiasis need re-evaluation, and the approach will change as more surgeons explore the bile ducts laparoscopically. Laparoscopic hiatal anti-reflux surgery will soon be routine, and a whole range of laparoscopically assisted operations on the oesophagus, colon, and rectum will become commonplace. Operations on the liver remain anecdotal. Throughout this rapid progress, surgeons must not forget the principles of (open) surgical practice, whilst carefully kept registers and regular audit of operations will provide new surgical standards.

The study investigates the effect of early enteral immunonutrition on patient recovery after extensive elective surgery in the upper abdomen [1,2]. It investigates the speed of patient recovery administering early enteral immunonutrition combined with total parenteral nutrition [3].