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Background Bariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Oesophago-Gastric (OG) malignancies in patients who have had a prior bariatric procedure have not been fully characterised. Objective To characterise OG malignancies after bariatric procedures. Setting University Hospital, United Kingdom. Methods We performed a retrospective, multi-centre observational study of patients with OG malignancies after bariatric surgery to characterise this condition. Results This study includes 170 patients from 75 centres in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years and the mean weight 128.8 ± 28.9 kg. Females comprised 57.3% (n=98) of the population. Most (n=64) patients underwent a Roux-en-Y Gastric Bypass (RYGB) followed by Adjustable Gastric Band (AGB) (n = 46) and Sleeve Gastrectomy (SG) (n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One-third of patients presented with metastatic disease. The majority of tumours were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under one year for most patients who died over the intervening period. Conclusions The OGMOS (Oesophago-Gastric Malignancies after Obesity/ Bariatric Surgery) study presents the largest series to date of patients developing OG malignancies after bariatric surgery and attempts to characterise this condition.

ObjectivesThe effective implementation of a fast-changing healthcare delivery innovation, such as robotic-assisted surgery (RAS), into a healthcare system, can be affected (both positively and negatively) by external contextual factors. As part of a wider project investigating ways to optimise the implementation of RAS, this qualitative study aimed to uncover current issues of RAS and predictions about the future of robotic surgery. We refer to ‘current issues’ as the topical and salient challenges and opportunities related to the introduction of RAS in the UK healthcare system, from the perspectives of key stakeholders involved in the delivery and implementation of RAS.DesignSemi-structured interviews and focus groups were conducted. A thematic analysis was conducted to summarise salient issues that were articulated by the participants.Setting and participantsThe interview sample (n=35) comprised surgeons, wider theatre staff and other relevant personnel involved in the introduction and delivery of RAS services across the UK, including service managers and policymakers/commissioners. Two focus groups were also conducted with surgical trainees (n=7) and members of the public (n=8), respectively.ResultsThe results revealed a largely positive attitude towards the introduction of RAS technology and an expectation of continued rapid expansion. Areas perceived to be particularly pertinent and requiring ongoing attention were also highlighted, including the need to achieve improved quality control, expertise quantification and training issues and the need to educate the public. Issues of centralisation, service organisation and equity of access were also emphasised.ConclusionsOur study has highlighted a range of issues perceived to be particularly pertinent to the current and future provision of RAS which should be addressed. The areas outlined can enable healthcare managers and surgeons to plan for the adoption and/or expansion of RAS services.

Gastric cancer has seen a considerable change in management, and outcomes for the past 30 years. Historically, the overall prognosis has been regarded as poor. However, the use of multimodal treatment, and integration of enhanced recovery pathways have improved short and long-term outcomes. The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for gastric cancers over 30 years.Data from consecutive patients undergoing gastrectomy with curative intent for gastric adenocarcinoma between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies and outcomes were reviewed. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends.Between 1989 and 2018, 1,162 patients underwent gastrectomy with curative intent for cancer. Median age was 71 years (interquartile range, 63-76 years) and 763 (66%) were male. Patient presentation changed with epigastric discomfort now the most common presentation (67%). An improvement in overall complications from 54% to 35% (P = .006) and mortality from 8% to 1% (P.001) was seen over the time period and overall survival improved from 28 months to 53 months (P.001).Both short-term and long-term outcomes have significantly improved over the 30 years studied. The reasons for this are multifactorial and include the use of perioperative chemotherapy, the introduction of an enhanced recovery pathway, and improved preoperative assessment of patients through a multidisciplinary input.

Introduction Esophagectomy is a key component in the curative treatment of esophageal cancer. Little is understood about the impact of smoking status on perioperative morbidity and mortality and the long-term outcome of patients following esophagectomy. Objective This study aimed to evaluate morbidity and mortality according to smoking status in patients undergoing esophagectomy for esophageal cancer. Methods Consecutive patients undergoing two-stage transthoracic esophagectomy (TTE) for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 1997 and December 2016 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable was smoking status, defined as current smoker, ex-smoker, and non-smoker. The primary outcome was overall survival (OS), while secondary outcomes included perioperative complications (overall, anastomotic leaks, and pulmonary complications) and survival (cancer-specific survival [CSS], recurrence-free survival [RFS]). Results During the study period, 1168 patients underwent esophagectomy for cancer. Of these, 24% (n = 282) were current smokers and only 30% (n = 356) had never smoked. The median OS of current smokers was significantly shorter than ex-smokers and non-smokers (median 36 vs. 42 vs. 48 months; p = 0.015). However, on adjusted analysis, there was no significant difference in long-term OS between smoking status in the entire cohort. The overall complication rates were significantly higher with current smokers compared with ex-smokers or non-smokers (73% vs. 66% vs. 62%; p = 0.018), and there were no significant differences in anastomotic leaks and pulmonary complications between the groups. On subgroup analysis by receipt of neoadjuvant therapy and tumor histology, smoking status did not impact long-term survival in adjusted multivariable analyses. Conclusion Although smoking is associated with higher rates of short-term perioperative morbidity, it does not affect long-term OS, CSS, and RFS following esophagectomy for esophageal cancer. Therefore, implementation of perioperative pathways to optimize patients may help reduce the risk of complications.

Background Thoracic epidural analgesia (TEA) has been regarded as the standard of care after oesophagectomy for pain control, but has several side-effects. Multimodal (intrathecal diamorphine, paravertebral and rectus sheath catheters) analgesia (MA) may facilitate postoperative mobilization by reducing hypotensive episodes and the need for vasopressors, but uncertainty exists about whether it provides comparable analgesia. This study aimed to determine whether MA provides comparable analgesia to TEA following transthoracic oesophagectomy. Methods Consecutive patients undergoing oesophagectomy for cancer between January 2015 and December 2018 were grouped according to postoperative analgesia regimen. Propensity score matching (PSM) was used to account for treatment selection bias. Pain scores at rest and on movement, graded from 0 to 10, were used. The incidence of hypotensive episodes and the requirement for vasopressors were evaluated. Results The study included 293 patients; 142 (48.5 per cent) received TEA and 151 (51.5 per cent) MA. After PSM, 100 patients remained in each group. Mean pain scores were significantly higher at rest in the MA group (day 1: 1.5 versus 0.8 in the TEA group, P = 0.017; day 2: 1.7 versus 0.9 respectively, P = 0.014; day 3: 1.2 versus 0.6, P = 0.047). Fewer patients receiving MA had a hypotensive episode (25 per cent versus 45 per cent in the TEA group; P = 0.003) and fewer required vasopressors (36 versus 53 per cent respectively; P = 0.016). There was no significant difference in the overall complication rate (71.0 versus 61.0 per cent; P = 0.136). Conclusion MA is less effective than TEA at controlling pain, but this difference may not be clinically significant. However, fewer patients experienced hypotension or required vasopressor support with MA; this may be beneficial within an enhanced recovery programme.

Background Chyle leak is an uncommon complication following esophagectomy, accounting for significant morbidity and mortality; however, the optimal treatment for the chylothorax is still controversial. Objective The aim of this study was to evaluate the incidence, management, and outcomes of chyle leaks within a specialist esophagogastric cancer center. Methods Consecutive patients undergoing esophagectomy for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between 1997 and 2017 at the Northern Oesophagogastric Unit were included from a contemporaneously maintained database. Primary outcome was overall survival, while secondary outcomes were overall complications, anastomotic leaks, and pulmonary complications. Results During the study period, 992 patients underwent esophagectomy for esophageal cancers, and 5% (n = 50) of them developed chyle leaks. There was no significant difference in survival in patients who developed a chyle leak compared with those who did not (median: 40 vs. 45 months; p = 0.60). Patients developing chyle leaks had a significantly longer length of stay in critical care (median: 4 vs. 2 days; p = 0.002), but no difference in total length of hospital stay. Conclusion Chyle leak remains a complication following esophagectomy, with limited understanding on its pathophysiology in postoperative recovery. However, these data indicate chyle leak does not have a long-term impact on patients and does not affect long-term survival.

Background Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes. Objective The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK. Patients and Methods Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends. Results Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p p p = 0.004). Conclusions Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.

Objective To determine the impact of downstaging on outcomes in esophageal cancer, the prognostic value of clinical and pathological stage, and the difference in survival in patients with similar pathological stages with and without neoadjuvant treatment. Background There is little data evaluating adenocarcinoma and squamous cell carcinoma (SCC) and difference in outcomes for similar pathological stage with and without neoadjuvant treatment. Patients and Methods Consecutive patients with esophageal cancer from a single center were evaluated. Patients with esophageal adenocarcinoma or SCC treated with transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM 8th edition was used. Results This study included 992 patients, of whom 417 received surgery alone and 575 received neoadjuvant therapy and surgery. In the neoadjuvant group, 7 (1%) had cTNM stage 2 and 418 (73%) had cTNM stage 3. Downstaging rates were similar between adenocarcinoma and SCC (54% vs. 61%, p = 0.5). Downstaging was associated with longer survival than patients with no change (adenocarcinoma, median: 82 vs. 26 months, p p Conclusions Pathological stage provides a better estimate of prognosis compared with clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage who did not receive neoadjuvant treatment.

Background This study aimed to determine whether trainee involvement in D2 gastrectomies was associated with adverse outcomes. Methods Data from a prospectively created database of consecutive patients undergoing open D2 total (TG) or subtotal (STG) gastrectomy with curative intent between January 2009 and January 2014 were reviewed. Short‐ and long‐term clinical outcomes were compared in patients operated on by consultants and those treated by trainees under consultant supervision. Results A total of 272 D2 open gastrectomies were performed, 123 (45·2 per cent) by trainees. There was no significant difference between consultants and trainees in median duration of surgery (TG: 240 (range 102–505) versus 240 (170–375) min respectively, P = 0·452; STG: 225 (150–580) versus 212 (125–380) min, P = 0·192), number of resected nodes (TG: 30 (13–101) versus 30 (11–102), P = 0·681; STG: 26 (5–103) versus 25 (1–63), P = 0·171), length of hospital stay (TG: 15 (7–78) versus 15 (8–65) days, P = 0·981; STG: 10 (6–197) versus 14 (7–85) days, P = 0·242), overall morbidity (TG: 44 versus 49 per cent, P = 0·314; STG: 34 versus 25 per cent, P = 0·113) or mortality (TG: 4 versus 2 per cent; P = 0·293). No difference in predicted 5‐year overall survival was noted between the two cohorts (TG: 68 per cent for consultants versus 77 per cent for trainees, P = 0·254; STG: 70 versus 75 per cent respectively, P = 0·512). The trainee cohort had lower median blood loss for both TG (360 (range 90–1200) ml versus 600 (70–2350) ml for consultants; P = 0·042) and STG (235 (50–1000) versus 360 (50–3000) ml respectively; P = 0·053). Conclusion Clinical outcomes were not compromised by supervised trainee involvement in D2 open gastrectomy., This study of 272 D2 gastrectomies investigated whether trainee involvement was associated with adverse outcomes. No significant difference in morbidity, mortality, operating time, number of nodes resected, hospital stay or predicted 5‐year survival was noted, demonstrating that outcomes are not compromised by supervised trainee involvement. Equally good performance

BackgroundEsophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence.ObjectiveThe aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer.MethodsConsecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien–Dindo grade III/IV complications.ResultsThis study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days;p p ConclusionThese results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact.

Background Benign anastomotic strictures (BAS) are a known risk of oesophageal resection, leading to significant post-operative morbidity and a reported incidence of BAS varies widely from 8.83% to 42.38%. This review aims to assess incidence, risk factors for development as well as treatment. Methods An electronic search using specific search terms using Medline, Embase and the Cochrane Library to identify all articles studying the development of BAS in adults post oesophagectomy was carried out. Inclusion criteria were patients who underwent any form of oesophagectomy for malignant disease (Ivor Lewis, McKeown, thoracoabdominal, transhiatal,minimally invasive); patients in study >18-year-old; study reported only benign anastomotic strictures and any study design with a minimum of 6 patients. Only articles published in the English language were included. Review articles, case reports and conference abstracts were all excluded Results Seven studies reported on the incidence of BAS and an average of 34.1% was found. Cervical anastomosis, anastomotic leak development. Cardiovascular disease, diabetes and gastric conduit and smaller gun size in a stapled anastomosis were also found to be associated with BAS. Hypertension, neoadjuvant chemotherapy, transhiatal oesophagectomy or transthoracic were not found to be associated with BAS. The mainstay of management appears to be endoscopic balloon dilatation with adverse reported outcomes related to stent management. Conclusions BAS after oesophagectomy is common. Several risk factors have been identified and balloon dilatation appears to be the mainstay of treatment.

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

Background Lymphadenectomy is essential for adequate oncological clearance and accurate staging during oesophagectomy for malignant disease. Adequate lymph node clearance has implications on patient outcomes and confers a survival benefit. Abdominal lymph node clearance may be technically challenging due to the location of nodes along key structures such as the common hepatic artery and splenic vessels. Robotic assistance during abdominal lymphadenectomy permits improved 3-D visualisation and instrument articulation in a potentially constricted space. This video demonstrates a technique for robotic abdominal lymphadenectomy during oesophagectomy. Methods This video demonstrates a technique for coeliac axis lymph node clearance during the abdominal phase of an oesophagectomy, as practiced at this institution. The intention for such a video is for ongoing appraisal and refinement of robotic techniques within the unit, as well as for teaching and training. The video was edited using iOS software, and text has been used to explain each step in conjunction with the images. Results Dissection of all relevant coeliac axis nodal stations is successfully demonstrated, with the lymph nodes resected en-bloc with the specimen. Text has also been used to explain the steps seen in the video images. Conclusions Robotic assistance permits safe and adequate lymphadenectomy during minimally invasive oesophagectomy, as demonstrated in this video.

Background Pain control is a vital component of enhanced recovery programmes for patients undergoing an oesophagectomy. Multimodal analgesia using intrathecal diamorphine and local anaesthetic infusion catheters into the paravertebral space and rectus sheath is increasingly utilised. Multimodal analgesia can provide comparable pain relief while potentially reducing side effects associated with thoracic epidurals. This video demonstrates the placement of paravertebral catheters following thoracoscopic oesophagectomy. Methods The video demonstrates the technique for paravertebral catheter placement at the end of the thoracic phase of an oesophagectomy, as practiced at our institution. Results Once the catheter has been placed and flushed, a bolus 15-20mls of 0.25 per cent Levobupivicaine is injected. A 600mls reservoir of Levobupivicaine is attached at the end of the procedure. Conclusions Paravertebral catheters provide a safe and feasible option for pain control following oesophagectomy.

Background Studies in patient literature particularly regarding online video literature in all fields are few. Scoring systems for video materials such as the validated PEMAT(Patient Education Material Assessment Tool) have been used before to look at video patient literature. The aim of this study is to use the PEMAT tool to evaluate the quality of Youtube patient literature on oesophageal cancer and look at the inter rater reliability between lay and medical scorers. Methods A Youtube search was performed in April 2021 using the search terms “oesophageal cancer”, “esophageal cancer” “gullet cancer”. Characteristic data collected included language, ratings (thumbs up), type of video, country of origin and presence of advertising as well as intended audience. A PEMAT tool which is validated instrument to rate patient video material was used. A score of 70% is acceptable in the actionability and understandability domains. Cohen’s kappa coefficient was used to test inter-rater reliability between two lay person raters; and two medical raters. Results Seven sites were rated as understandable by the medical raters average and 13 were rated understandable by the lay raters average. Only two videos achieved best case scenario where both medical raters rated as understandable, rather than the average of both. Twelve videos were rated by both lay raters as understandable. Actionability rated poorer with only two videos rated as actionable on average by the medical raters and seven rated actionable by the lay raters on average. Conclusions Youtube videos on Oesophageal cancer score poorly in terms of actionability and understandability.

Patients with locally advanced esophageal cancer usually receive neoadjuvant treatment prior to surgery. A proportion of patients will not receive their surgery due to disease progression. Little is known about what happens to these patients and their prognosis. The aim of this study was to evaluate outcomes in patients that have received neoadjuvant treatment but not undergone esophagectomy. Methods A review of a contemporaneously maintained database of all patients that underwent neoadjuvant treatment for esophageal adenocarcinoma, or squamous cell carcinoma (SCC) but did not have a subsequent esophagectomy was carried out. Patients that were diagnosed with cancer between January 2009 and December 2018 were included. All patients underwent a standardised staging protocol, and were restaged on completion of their neoadjuvant treatment. Overall survival from the date of their initial staging CT and any subsequent treatments were recorded. Results Over the time period 927 patients received neoadjuvant treatment, and 107 did not progress to surgery. Of the 107, 106 received neoadjuvant chemotherapy and one chemoradiotherapy. 83 of the 107 were adenocarcinoma and 24 SCC. The median age of patients who had surgery was 66 compared to 67 for those that did not. Overall median survival for patients not having surgery was 328.5 days. 40 patients had subsequent oncological treatments. Median survival for patients who received no further treatment was 264 days, palliative chemotherapy 412 days palliative radiotherapy 418.5 days and any combination of the two was 390.5 days. Conclusion These results show median survival after disease progression during neoadjuvant treatment was over 10 months and this was extended with further oncological treatment with radiotherapy prolonging survival times the most to over 13 months. This information can help when counselling patients to potential treatment options.

Debate remains regarding the extent of lymphadenectomy required with esophagectomy. In patients who receive neoadjuvant treatment, this may address lymph node metastases. However, patients with early disease and those with comorbidities may not receive neoadjuvant treatment. The aim of this study is to determine the impact of lymph node yield and location on prognosis in patients undergoing esophagectomy without neoadjuvant treatment. Data from consecutive patients with potentially curable adenocarcinoma of the esophagus or gastroesophageal junction were reviewed. Patients were treated with transthoracic esophagectomy and two-field lymphadenectomy. Outcomes according to lymph node yield were determined. The prognosis of carrying out less radical lymphadenectomy was calculated according to three groups: exclusion of proximal thoracic nodes (group 1), minimal abdominal lymphadenectomy (group 2), and minimal abdominal and thoracic lymphadenectomy (group 3). 357 patients were included. Median survival was 78 months [confidence interval (CI) 53–103 months]. Absolute lymph node retrieval was not related to survival (p = 0.920). An estimated additional 4 (2–6) cancer-related deaths was projected if group 1 nodes were omitted, 15 (11–19) additional deaths if group 2 nodes were omitted, and 4 (2–6) deaths if group 3 nodes were omitted. Minimal lymphadenectomy (groups 1, 2, and 3) was projected to lead to 19 (15–23) additional cancer-related deaths. Extensive lymphadenectomy allows accurate staging. In patients who do not receive neoadjuvant treatment, it may confer a survival benefit. The number of lymph nodes retrieved may not be a good surrogate for extent of lymphadenectomy, and correlation with location is required.

SUMMARY Changes in the structure of surgical training have affected trainees’ operative experience. Performing an esophagectomy is being increasingly viewed as a complex technical skill attained after completion of the routine training pathway. This systematic review aimed to identify all studies analyzing the impact of trainee involvement in esophagectomy on clinical outcomes. A search of the major reference databases (Cochrane Library, MEDLINE, EMBASE) was performed with no time limits up to the date of the search (November 2017). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Four studies that included a total of 42 trainees and 16 consultants were identified, which assessed trainee involvement in open esophagogastric resectional surgery. A total of 1109 patients underwent upper gastrointestinal procedures, of whom 904 patients underwent an esophagectomy. Preoperative characteristics, histology, neoadjuvant treatment, and overall length of hospital stay were comparable between groups. One study found higher rates of anastomotic leaks in procedures primarily performed by trainees as compared to consultants (P < 0.01)—this did not affect overall morbidity or survival; however, overall anastomotic leak rates from the published data were 10.4% (trainee) versus 6.3% (trainer) (P = 0.10). A meta-analysis could not be performed due to the heterogeneity of data. The median MINORS score for the included studies was 13 (range 11–15). This study demonstrates that training can be achieved with excellent results in high-volume centers. This has important implications on the consent process and training delivered, as patients wish to be aware of the risks involved with surgery and can be reassured that appropriately supervised trainee involvement will not adversely affect outcomes.

Thoracic epidural (TE) analgesia has been the gold standard for pain management post-esophagectomy and is still being widely used. While it offers excellent analgesia, it can negatively impact on recovery due to hypotension. An alternative is multimodal analgesia using intrathecal-diamorphine, paravertebral and rectus sheaths local anaesthetic infusion-catheters (LAC) and intravenous opioids (PCA). The aim of this study was to compare the effectiveness of TE analgesia and multimodal LAC analgesia and the associated incidence of hypotension. Methods Data were collected over a three-year period for patients who underwent trans-thoracic (Ivor Lewis) esophagectomy from a single high volume unit. Multimodal analgesia was integrated into the patient pathway in early 2016 and adopted by all team members. All patients were treated post operatively with a standardised enhanced recovery pathway. Pain scores using a visual analogue scale (VAS) at rest and movement, episodes of hypotension (systolic BP Results Overall 239 patients were included in this study, 104 patients received TE analgesia and 135 patients received multimodal analgesia. There was no statistically significant difference in the mean VAS pain scores between both cohorts on all post-operative days. (p = 0.06–0.89). In comparison to TE analgesia, the multimodal patient group had significantly fewer episodes of hypotension (multimodal: 21% vs TE: 38%, p = 0.01) and significantly less vasopressor infusion requirements to maintain their blood pressure (multimodal: 30% vs TE: 55%, p = 0.01). Conclusion Multimodal analgesia using intrathecal diamorphine with combined paravertebral and rectus sheath catheters is not inferior to TE in providing pain control post esophagectomy. In addition there are significantly fewer episodes of hypotension and significantly less need for vasopressor use. This may confer a postoperative advantage permitting better patient mobilisation and recovery in the immediate post operative period.

Laparoscopic repair remains the approach of choice for the surgical management of symptomatic paraesophageal hernia (PEH), although robotic techniques are becoming increasingly popular. The learning curve for minimally invasive PEH repair can be variable and little is known of its potential impact upon surgical residents’ training. The aim of this review is to appraise current literature on learning curves in PEH repair and its impact on training and mentorship of surgical residents. Methods Literature searches were performed in three databases: MEDLINE (1980-2020), EMBASE and the Cochrane Library. Search results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data quality was assessed in accordance with the Newcastle-Ottawa Scale for cohort studies. Results A total of 6 studies were identified; 4 laparoscopic and 2 robotic assisted with 2678 patients assessed in total. One study used a cumulative sum (CUSUM) analysis to define learning with the remainder of studies using between 3 and 11 parameters. 2 studies evaluated trainees’ performance in performing laparoscopic PEH repair when mentored by surgeons who had achieved competence on the learning curve. Both studies reported equivalent clinical outcomes for laparoscopic PEH repair performed by trainees versus consultants, although one study suggested 5-year outcomes were inferior in the trainee group despite mentorship. Conclusion Despite being commonly performed, little is known about the learning curves for minimally invasive PEH repair. Furthermore, whether prior laparoscopic experience confers any advantage to performing robotic PEH repair is not known at present. Further data to help evaluate the learning curve for those performing PEH is required in order to enhance training and permit quicker attainment of competency.

Minimally invasive techniques are being increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy (MIE) is variable and can have an impact upon training delivered within residency and fellowship programmes. The aims of this review are to critically appraise current literature on the learning curve for MIE, identify what parameter(s) is used to quantify achieving competence and determine if there is evidence of resultant impact on surgical training. Methods A search of the major reference databases (MEDLINE, EMBASE, Cochrane) was performed with no time limits up to the date of the search (February 2020). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the Newcastle-Ottawa Scale for cohort studies. Results Twenty-one studies comprising 2720 patients were included- 17 studies reported on a combination of thoracoscopic, hybrid and total MIE, 3 studies reported robotic assisted alone and 1 study evaluated robotic assisted and thoracoscopic esophagectomy. 3 studies used a cumulative sum (CUSUM) analysis to define learning, 1 study used CUSUM and another parameter and 17 studies used one or more parameters. Quantification of surgical competence was variable and ranged from 12–80 cases for robotic surgery and 12–60 cases for other modes of MIE. One study reported trainees achieving MIE skills quicker if mentoring surgeons had attained proficiency on the learning curve. Conclusion Learning curves in MIE remain ill-defined with limited evidence on impact upon training received by residents and fellows. Additionally, the parameters used to define achievement of surgical competency is heterogenous. As minimally invasive techniques are increasingly adopted, specific standards to help define competence need to be identified and agreed on. This could help in designing training programmes and improve the rate of achieving competency.

Summary Background The COVID-19 pandemic continues to have a significant impact on the provision of medical care. Planning to ensure there is capability to treat those that become ill with the virus has led to an almost complete moratorium on elective work. This study evaluates the impact of COVID-19 on cancer, in particular surgical intervention, in patients with esophago-gastric cancer at a high-volume tertiary center. Methods All patients undergoing potential management for esophago-gastric cancer from 12 March to 22 May 2020 had their outcomes reviewed. Multi-disciplinary team (MDT) decisions, volume of cases, and outcomes following resection were evaluated. Results Overall 191 patients were discussed by the MDT, with a 12% fall from the same period in 2019, including a fall in new referrals from 120 to 83 (P = 0.0322). The majority of patients (80%) had no deviation from the pre-COVID-19 pathway. Sixteen patients had reduced staging investigations, 4 had potential changes to their treatment only, and 10 had a deviation from both investigation and potential treatment. Only one patient had palliation rather than potentially curative treatment. Overall 19 patients underwent surgical resection. Eight patients (41%) developed complications with two (11%) graded Clavien-Dindo 3 or greater. Two patients developed COVID-19 within a month of surgery, one spending 4 weeks in critical care due to respiratory complications; both recovered. Twelve patients underwent endoscopic resections with no complications. Conclusion Care must be taken not to compromise cancer treatment and outcomes during the COVID-19 pandemic. Excellent results can be achieved through meticulous logistical planning, good communication, and maintaining high-level clinical care.

Summary To compare long-term and short-term outcomes in patients

Summary Locally advanced esophageal cancer is associated with poor long-term survival. Pre- and post-treatment stages may differ because of neoadjuvant therapy and inaccuracies in staging. The aim of this study was to determine the outcomes of patients staged with clinical T3 N3 and pathological T3 N3 carcinoma of the esophagus and determine differences between the groups. Consecutive patients from a single unit between 2010 and 2018 were included with either clinical (cT3 N3) or pathological (pT3 N3) esophageal cancer. Outcomes were compared between patients that underwent esophagectomy with or without neoadjuvant treatment and those patients staged cT3 N3 treated non-surgically (NSR). Patients were staged using the TNM 8. This study included 156 patients, 63 patients were staged cT3 N3 initially and had NSR treatment, only three of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were initially staged as cT3 N3, 54 were found to be pT3 N3 having been staged earlier initially, and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3 N3 patients was significantly longer than pT3 N3 and NSR (median: NR vs 19 vs 8 months, P

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

Background Raised levels of systemic inflammatory markers are associated with poor survival in patients with cancer. The aim of this study was to assess the prognostic value of markers of systemic inflammation in patients with adenocarcinoma of the oesophagus or gastro-oesophageal junction. Methods Data from a consecutive series of patients undergoing transthoracic oesophagectomy following neoadjuvant therapy at a single centre were analysed. Fibrinogen, albumin, C-reactive protein, leucocyte differential and platelet counts were measured before surgery. The upper quartile (75th percentile) was used as a cut-off for dichotomization. Multivariable regression analysis was performed to identify independent prognostic factors. Results A series of 199 patients underwent transthoracic oesophagectomy following neoadjuvant therapy. Univariable analysis indicated that reduced median survival was associated with a raised platelet : lymphocyte ratio (158 or above; 25.6 versus 44·4 months for patients with a normal ratio, P = 0·038) and increased fibrinogen levels (4·9 g/l or above; 22·8 versus 59·9 months for those with a normal level, P = 0·005). On multivariable analysis a combination of one or more markers of systemic inflammation was associated with poorer overall survival (hazard ratio 2·12, 95 per cent c.i. 1·20 to 3·74; P = 0·010). Conclusion Preoperative markers of systemic inflammation predict poor outcome in patients undergoing curative treatment for locally advanced oesophageal and gastro-oesophageal adenocarcinoma.

Aim The aim of this study was to determine the importance of cTNM and ypTNM, and impact of downstaging of disease in patients with esophageal or gastro-eesophageal junction (GOJ) carcinoma who received neoadjuvant treatment followed by surgery. Background Most locally advanced esophageal cancers are treated with neoadjuvant therapy (chemotherapy or chemoradiotherapy). TNM staging is used prior (cTNM) and after (ypTNM) neoadjuvant treatment and surgery. Methods Data from consecutive patients with esophageal cancer from a single center were evaluated. Patients with either adenocarcinoma or squamous cell carcinoma of the esophagus who were treated with neoadjuvant chemo(radio) therapy followed by transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM were applied and compared according to the American Joint Commission on Cancer (AJCC) 8th edition staging system. Results This study included 1115 patients of which 486 patients received surgery alone and 629 patients received neoadjuvant therapy and resection. Of patients receiving neoadjuvant therapy, 9 (1%) had cTNM stage 2 and 451 (72%) had a cTNM stage 3. Rates of downstaging were similar in esophageal adenocarcinoma and SCC (54% vs 62%, p=0.4). Downstaging was associated with significantly longer survival than patients with no change for both adenocarcinoma (median: 48 vs 15 months, p Conclusion This study demonstrates ypTNM stage is provides a better estimate of prognosis compared to clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage that did not receive neoadjuvant treatment.

Aim To evaluate the outcomes patients undergoing endoscopic mucosal resection (EMR) as a therapeutic and or diagnostic treatment for oesophageal cancer. Background Management of early oesophageal cancer usually involves major surgery (oesophagostomy) which has a reported morbidity of 50% and mortality of 3%. EMR is increasingly used as a treatment for patients with early (T1 N0) oesophageal cancer. It may also be employed as a diagnostic tool in those where previous biopsies have been insufficient in proving a cancer. Methods A retrospective review of patients who underwent EMR with a curative intent for cancer of the oesophagus or oesophago-gastric junction (OGJ) at a single centre between October 2006 and February 2019 was conducted. Patients were included in the study if the EMR sample was positive for T1a or T1b cancer. Results Overall 144 patients were identified who underwent 276 therapeutic or diagnostic procedures. 141 patients were diagnosed with adenocarcinoma and 3 patients with squamous cell cancer (SCC). T1a stage was confirmed for 120 patients with adenocarcinoma and one with SCC. 21 patients with adenocarcinoma and 2 with SCC were staged as T1b. 78 patients underwent EMR as their sole treatment for cancer- three year cancer related survival was 89% and 5 year 69%. A further 49 patients progressed to having surgery (gastrectomy (2), trans-thoracic oesophagectomy (47). Six (12%) were node positive. There was no mortality associated with EMR, however bleeding requiring intervention or readmission was observed after 29 procedures (11%) and perforation was seen after 3 procedures (1.1%). Conclusion EMR is a safe procedure in the treatment of early oesophageal or OG junctional cancer. However survival may not be as high as expected in patients similarly staged but undergoing more radical treatment.

Background Chyle leaks may result from damage of the main thoracic duct or its tributaries during radical en-bloc sub-total oesophagectomy (STO). Treatment strategies and outcomes vary and management of this problem remains controversial. This study assessed the incidence, management and outcomes of chyle leaks in a dedicated oesophago-gastric cancer unit. Methods A retrospective study was conducted among patients who underwent elective STO with 2-field nodal dissection for oesophageal cancer between January 1997 and March 2019. The thoracic duct was routinely ligated during surgery. The diagnosis of post-operative chyle leak was performed clinically by a consultant and it was based on high output (> 500 ml/24h) from chest and/or abdominal drains and on visual characteristics of the fluid. Results 1320 patients underwent surgery over the time reviewed. The study group consisted of 347 (26.3%) women and 974 (73.7%) men, with a median age of 65 (IQR 13) years. Oesophageal adenocarcinoma was diagnosed in a total of 937 (70.9%) patients, while squamous cell carcinoma in 274 (20.7%) patients. 93 (7%) patients developed a chylothorax. Univariable analysis showed that lower body weight, lower BMI, female sex and histology of a squamous cell carcinoma were significant independent predictive factors for chyle leak (p Chyle leak was associated with a higher risk of return to ITU (45.1% vs 10.1%, p Chylothorax was treated surgically in 39 (41.9%) patients and conservatively in 54 (58.1%). Between these two groups, a significant difference in terms of post-operative hospital stay and in 30-day mortality rate was seen (p< 0.002 and p=0.031, respectively). Survival rate was similar in both groups. Conclusions Chyle Leak post oesophagectomy is associated with an increased risk of return to ITU, and longer hospital stay and increased in hospital mortality. However, surgical treatment is safe and early re-operation is recommended in order to diminish hospital stay and to decrease the 30-day mortality rate.

Objective To identify the prognostic significance of the location of lymph node metastases in patients with esophageal or gastroesophageal junction (GEJ) adenocarcinoma treated with neoadjuvant therapy followed by esophagectomy. Background Detection of lymph node metastases in the upper mediastinum and around the celiac trunk after neoadjuvant therapy and resection does not alter the TNM classification of esophageal carcinoma. The impact of these distant lymph node metastases on survival remains unclear. Methods Between March 2003 and September 2013, 479 consecutive patients with adenocarcinoma of the distal esophagus or GEJ who underwent transthoracic esophagectomy with en bloc 2-field lymphadenectomy after neoadjuvant therapy were included, and survival was analyzed according to the location of positive lymph nodes in the resection specimen. Results Two hundred fifty-three patients had nodal metastases in the resection specimen. Of these patients, 92 patients had metastases in locoregional nodes, 114 patients in truncal nodes, 21 patients in the proximal field of the chest, and 26 patients had both positive truncal and proximal field nodes. Median disease-free survival was 170 months in the absence of nodal metastases, 35 months for metastases limited to locoregional nodes, 16 months for positive truncal nodes, 15 months for positive nodes in the proximal field, and 8 months for nodal metastases in both truncal and the proximal field. On multivariate analysis, location of lymph node metastases was independently associated with survival. Conclusions Location of lymph node metastases is an independent predictor for survival. Relatively distant lymph node metastases along the celiac axis and/or the proximal field have a negative impact on survival. Location of lymph node metastases should therefore be considered in future staging systems of esophageal and GEJ adenocarcinoma.

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

Thoracic epidural (TE) analgesia has been the standard of care for transthoracic esophagectomy patients since the 1990s. Multimodal anesthesia using intrathecal diamorphine, local anesthetic infusion catheters (LAC) into the paravertebral space and rectus sheaths and intravenous opioid postoperatively represent an alternative option for postoperative analgesia. While TE can provide excellent pain control, it may inhibit early postoperative recovery by causing hypotension and reducing mobilization. The aim of this study is to determine whether multimodal analgesia with LAC was effective with respect to adequate pain management, and compare its impact on hypotension and mobility. Patients receiving multimodal LAC analgesia were matched using propensity score matching to patients undergoing two-phase trans-thoracic esophagectomy with a TE over a two-year period (from January 2015 to December 2016). Postoperative endpoints that had been evaluated prospectively, including pain scores on movement and at rest, inotrope or vasoconstrictor requirements, and hypotension (systolic BP < 90 mmHg), were compared between cohorts. Out of 14 patients (13 male) that received LAC were matched to a cohort of 14 patients on age, sex, and comorbidity. Mean and maximum pain scores at rest and movement on postoperative days 0 to 3 were equivalent between the groups. In both cohorts, 50% of patients had a pain score of more than 7 on at least one occasion. Fewer patients in the LAC group required vasoconstrictor infusion (LAC: 36% vs. TE: 57%, P = 0.256) to maintain blood pressure or had episodes of hypotension (LAC: 43% vs. TE: 79%, P = 0.05). The LAC group was more able to ambulate on the first postoperative day (LAC: 64% vs. TE: 43%, P = 0.14) but these differences were not statistically significant. Within the epidural cohort, three patients had interruption of epidural due to dislodgement or failure of block compared to no disruption in the multimodal local anesthesia catheters group (P = 0.05). Therefore, multimodal anesthesia using spinal diamorphine with combined paravertebral and rectus sheath local anesthetic catheters appears to provide comparable pain relief post two-phase esophagectomy and may provide more reliable and safe analgesia than the current standard of care.

Gastrointestinal stromal tumours (GISTs) most commonly originate from the stomach. Their treatment is dependent on size and whether they are symptomatic. Curative treatment requires surgery, which may be preceded by neoadjuvant imatinib if it is felt that this will aid in achieving clear (R0) resection margins. The aim of this study was to evaluate outcomes from patients that underwent a “local” organ-preserving operation, with those that required a more radical resection, and the influences on selecting a more radical resection. A retrospective review of patients undergoing surgery for symptomatic gastric GISTs from a single institution over 9 years was carried out. Patients were divided into three cohorts dependent on whether they had a “local” resection, “anatomical” resection, or “extended” resection. 71 patients were included. Overall, 5-year survival was 92%. Operating time, blood loss, and length of stay were significantly lower in the group undergoing local resection (p<0.05). Tumour size was also smaller in the local group (median 4 cm versus 5 cm p<0.05). Tumour location also influenced the type of surgery performed, with tumours at the cardia, gastroesophageal junction, and antrum all having “anatomical” resections. Lymphadenectomy did not appear to impact on outcomes. These findings indicate that local excision, where possible, does not impair oncological outcomes.

Background: In patients treated for oesophageal cancer the importance of lymphovascular and perineural invasion (PNI) after neoadjuvant therapy has yet to be established. The aim of this study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy. Methods: Clinical and pathology results from patients with potentially curable adenocarcinoma, or squamous cell carcinoma of the oesophagus or GOJ were reviewed. Patients were treated with neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of venous invasion (VI), lymph vessel invasion (LI) and perineural invasion (PNI) were correlated with clinical outcomes. Results: A total of 396 patients underwent oesophagectomy after neoadjuvant therapy for oesophageal cancer. Venous invasion was identified in 150 (38%) of patients, LI in 203 (51%) patients and PNI in 204 (52%) patients. In all, 123 (31%) patients had no evidence of either VI, LI or PNI. A total of 96 (24%) had a combination of two factors and 94 (24%) had all three factors. The presence of VI, LI and PNI was significantly related to tumour stage (P=0.001). Median overall survival was 170.8 months when all three factors were absent, 44.0 months when one factor was present, 27.1 months when two factors were present and 16.0 months when all were present. Multivariate analyses revealed VI, LI and PNI or a combination of these factors were independent predictors of prognosis. Conclusions: In oesophageal cancer patients treated with neoadjuvant therapy followed by oesophagectomy the presence of VI, LI and PNI has an important prognostic impact and may identify patients at high risk of recurrence who would benefit from adjuvant therapies.

The aim of the present study was to determine whether trainee involvement in esophageal cancer resection is associated with adverse patient outcomes. Operative experience for surgical trainees is under threat. A number of factors have been implicated in this leading to fewer hours for training. Esophagogastric cancer training is particularly vulnerable due to the publication of individual surgeon results and a perception that dual consultant operating improves patient outcomes. Resectional surgery is increasingly viewed as a subspeciality to be developed after completion of the normal training pathway. Data from a prospectively maintained database of consecutive patients undergoing trans-thoracic esophagectomy for potentially curable carcinoma of the esophagus or gastroesophageal junction were reviewed. Patients were divided into 4 cohorts, according to whether a consultant or trainee was the primary surgeon in either the abdominal or thoracic phase. Outcomes including operative time, lymph node yield, blood loss, complications graded by Accordion score, and mortality were recorded. A total of 323 patients underwent esophagectomy during 4 years. The overall in-hospital mortality rate was 1.5%. At least 1 phase of the surgery was performed by a trainee in 75% of cases. There was no significant difference in baseline demographics of age, stage, neoadjuvant treatment, and histology between cohorts. There was no significant difference in blood loss (P = 0.8), lymph node yield (P = 0.26), length of stay (P = 0.24), mortality, and complication rate according to Accordion scores (P = 0.21) between cohorts. Chest operating time was a median 25 minutes shorter when performed by a consultant (P < 0.001). These findings demonstrate that patient outcomes are not compromised by supervised trainee involvement in transthoracic esophagectomy. Training is an essential role of all surgical units and training data should be more widely reported especially in areas of high-risk surgery.

Cystic fibrosis (CF) is a multisystem disorder characterized by progressive lung disease. Life expectancy is, however, continually improving. Patients with CF will therefore present with an increasing number of conditions, some of which will require operative management. We present our experience of the management of a patient with CF who underwent a subtotal esophagectomy for adenocarcinoma of the esophagus. No significant difficulties were encountered in the perioperative management of the patient. Despite a decline in his lung function and weight postoperatively, he remains clinically stable. Major surgery can be successfully undertaken in selected patients with CF.

Background The significance of extracapsular lymph node involvement (LNI) is unclear in patients with oesophageal cancer who have undergone neoadjuvant treatment followed by oesophagectomy. The aim of this study was to assess the incidence and prognostic significance of extracapsular LNI in a large multicentre series of consecutive patients with oesophageal cancer treated by neoadjuvant chemotherapy or chemoradiotherapy and surgery. Methods Data from a consecutive series of patients treated at two European centres were analysed. All patients with squamous cell carcinoma or adenocarcinoma of the oesophagus or gastro-oesophageal junction, who received neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy with curative intent, were included. Results Between January 2000 and September 2013, 704 patients underwent oesophagectomy after neoadjuvant therapy. A median of 28 (range 5–77) nodes per patient was recovered. Some 347 patients (49·3 per cent) had no LNI (ypN0). Of the remaining 357 patients (50·7 per cent) with LNI (ypN1–3), extracapsular LNI was found in 190 (53·2 per cent). Five-year overall survival rates were 62·7 per cent for patients with N0 disease, 44·9 per cent for patients without extracapsular spread and 14·0 per cent where extracapsular LNI was identified (P < 0·001). Multivariable analyses demonstrated the presence of extracapsular LNI as an independent prognostic factor. Conclusion The presence of extracapsular LNI after neoadjuvant therapy carries a poor prognosis.

Transoral incisionless fundoplication (TIF) using the EsophyX™ system has been introduced as a possible alternative for the treatment of gastroesophageal reflux disease (GERD). The efficacy of this procedure in our centers was evaluated. Patients were selected for treatment if they had typical GERD symptoms, failed management with proton pump inhibitors (PPIs), a positive esophageal pH test with symptom correlation, and no hiatus hernia larger than 2 cm. Nineteen patients (11 men, 8 women) underwent the TIF procedure between April 2008 and July 2009. Mean age was 48.2 years and body mass index was 24.6. The major complication rate was 3/19, including esophageal perforation, hemorrhage requiring transfusion, and permanent numbness of tongue. At mean 10.8 months follow-up, 5/19 had completely discontinued PPIs, and 3/19 had decreased their PPI dose. However, 10/19 had been converted to laparoscopic fundoplication for recurrent reflux symptoms and an endoscopically confirmed failed valve. Nine of 17 were dissatisfied with the outcome, and eight were satisfied. Thirteen of 19 (68%) were considered to have been unsuccessful. At short-term follow-up, the TIF procedure is associated with an excessive early symptomatic failure rate, and a high surgical re-intervention rate. This procedure should not be performed outside of a clinical trial.

Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.

Background Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality. Methods All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database. Results A total of 390 oesophagectomies were performed (median age 65 (range 32–81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52–80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15–159) days; none of these patients died. Conclusion Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.

Darrien JH, Kasem H Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome. Ann R Coll Surg Engl 2013; 95: 552–556 doi 10.1308/003588413X13629960049315

Barrett's esophagus results from the long-term effects of both acid and bile reflux. After subtotal esophagectomy and reconstruction with a gastric tube, many patients experience profound reflux. Development of Barrett's epithelium in the esophageal remnant has been reported. Here we report the case of a man who was diagnosed with adenocarcinoma in his esophageal remnant on a background of Barrett's change 52 years after undergoing one of the first esophageal resections for benign disease as a child.

Introduction The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement. Not only the amount of positive lymph nodes but also the location of postive nodes negatively influence survival. Earlier small studies revealed a poor survival for patients with positive nodes in the proximal field of the chest when treated with surgery alone. It is thus far unknown what the relevance of these nodes is after neoadjuvant therapy. The aim of the present study was to identify the incidence and prognostic significance of lymph node metastases in the proximal part of the chest in patients who underwent a transthoracic oesophagectomy after neoadjuvant therapy. Method From a prospectively collected database, a consecutive series of patients in two high volume centres in Europe was analysed. All patients with potentially curable adeno carcinoma of the gastro-oesophageal junction were treated with neoadjuvant chemo (radiation)therapy therapy followed by transthoracic oesophagectomy and two-field lymphadenectomy. Results Between January 2000 and September 2013 a consecutive series of 208 patients underwent an oesophagectomy after neoadjuvant therapy for adenocarcinoma of the gastro-oesophageal junction. 80 (38.5%) patients had no evidence of lymph node metastases (N0). There were 128 patients (61.5%) with positive nodes (N1=41 (19.7%), N2=44 (21.2%), N3=43 (20.7%)). Of the node positive patients, 25 (19.5%) had positive nodes in the proximal field of the chest (paratracheal, subcarinal, bronchial and aorto-pulmonary window lymph nodes). More advanced N-stage was significantly associated with positive nodes in the proximal field of the chest (p Conclusion Lymph node metastases in the proximal part of the chest in patients is a common phenomonemon and a sign of advanced disease. Radical surgical resection can only be achieved with an extended transthoracic resection. Even after neoadjuvant therapy followed by transthoracic resection long-term survival is poor. Disclosure of interest None Declared.

Introduction In patients with oesophageal cancer, little attention has been paid to the relevance of tumour invasion in blood (AI) and lymphatic vessels (LVI) as well as perineural invasion (PNI) after neoadjuvant therapy. Therefore, the aim of the present study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy. Method From a prospectively collected database, a consecutive series of patients was analysed. All patients with potentially curable adeno- or squamous cell carcinoma of the oesophagus or GOJ were treated with neoadjuvant chemotherapy or chemoradiation therapy followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of AI, LVI and PNI was prospectively collected. Results Between January 2000 and September 2013, a consecutive series of 396 patients underwent a potentially curative oesophagectomy after neoadjuvant therapy for adeno- or squamous cell carcinoma. AI was seen in 150 (38%) of patients, LVI was seen in 203 (51%) of patients and PNI was seen in 204 (52%) of patients. 123 (31%) had no AI, LVI or PNI whatsoever. 96 (24%) had a combination of two out of three factors and 94 (24%) had presence of AI, LVI and PNI. The presence of AI, LVI and PNI was significantly (P = 0.001) related with ypT- and ypN-stage. Median overall survival was 170.8 months (95% CI: 68.9–272.8) if AI, LVI and PNI were all absent, 44.0 months (95% CI: 20.9–67.2) when one factor was present, 27.1 months (95% CI: 22.8–31.4) when two factors were present and 16.0 months (95% CI: 9.4–22.6) when AI, LVI and PNI were all present. On multivariate analyses the presence of AI, LVI and PNI or a combination of these factors were independent predictors. Conclusion These findings suggest the importance of the presence of AI, LVI and PNI after neoadjuvant therapy followed by oesophagectomy. The presence of AI, LVI and PNI should be incorporated in the standardised pathology report. It provides additional information for identyfying patients at high risk who may be candidates for adjuvant therapies. Disclosure of interest None Declared.

Introduction The presence of lymphatic dissemination in oesophageal cancer affects prognosis. The relevance of location of an involved solitary lymph node is unclear. The concept of sentinel node guided lymphadenectomy to reduce surgical stress of a transthoracic operation has some advocates. However, the site of solitary lymph node metastasis, is unpredictable. Similarly, metastases to anatomically distant lymph nodes, known as skip lesions, could develop in the early phase of lymphatic invasion. The aim of this study was to examine the pattern of a single named lymph node metastasis in patients with oesophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who underwent resection with curative intent. No study to date has investigated this concept. Method Results of consecutive patients from a prospectively maintained database were analysed. All patients with potentially curable AC or SCC who underwent a radical two-field, two-stage, transthoracic oesophagectomy were included. Ex-vivo surgical dissection of the specimen was carried out post-operatively by the surgeon, with harvested lymph node stations labelled. This permitted accurate ‘lymph node mapping’. All harvested lymph nodes were examined by a consultant histopathologist. Results Between 1995 and 2014 a total of 120 patients with one positive lymph node who had undergone a radical two-field, two-stage oesophagectomy were identified. A median age of 65 (45–80) was observed. Seventy three ACs and 47 SCCs were noted. Twenty three middle oesophageal (19.2%), 54 lower oesophageal (45%) and 43 (35.8%) junctional tumours were resected. There was no difference between patterns of solitary lymphatic metastases between AC and SCC. The pattern and number of solitary lymph node metastasis is as follows: paracardial 34 (28.3%); paraoesophageal 31 (25.8%); left gastric 28 (23.3%); subcarinal/bronchial 10 (8.3%) and truncal/coeliac/splenic 9 (7.5%). Tumour location and corresponding single node metastasis are summarised in Table 1. Median survival for patients with AD and SCC were similar at 45 months and 52 months respectively (p = 0.84). Conclusion This study provides further support to the concept that metastasis to anatomically distant lymph nodes (skip metastasis), could develop even in the early phase of lymphatic invasion in oesophageal carcinoma. This unpredictability necessitates a radical resection. This can only be achieved with an extended transthoracic operation to allow a complete two-field lymphadenectomy in order to provide locoregional clearance and a potentially curative resection. Disclosure of interest None Declared.

Introduction In patients with oesophageal cancer, little attention has been paid to the biological significance of extracapsular lymph node involvement (LNI) in patients who underwent neoadjuvant treatment followed by oesophagectomy. Therefore, the aim of the present study was to assess the incidence, extent of extracapsular LNI and prognostic significance in a consecutive multicenter series of patients with cancer of the oesophagus or gastro-esophageal junction (GOJ) who underwent neoadjuvant chemo (radio) therapy followed by surgery. Method From a prospectively collected database, a consecutive series of patients in two high volume centres in Europe was analysed. All patients with potentially curable adeno- or squamous cell carcinoma of the oesophagus or GOJ were treated with neoadjuvant chemotherapy or chemoradiation therapy followed by transthoracic oesophagectomy and two-field lymphadenectomy. Results Between January 2000 and September 2013 a consecutive series of 704 patients underwent an oesophagectomy after neoadjuvant therapy. A median number of 28 (5–77) nodes was resected and identified. 347 (49.3%) patients had no evidence of lymph node metastases (ypN0). There were 357 (50.7%) patients with positive nodes (ypN1-N3). Extracapsular LNI was identified in 190 (53.2%) of lymph node positive patients. Five-year overall survival rates were 63% for N0 patients, 45% for patients with intracapsular LNI and 14% for patients with extracapsular LNI (p Conclusion The presence of extracapsular LNI after neoadjuvant chemo (radiation) therapy identifies a subgroup of patients with a significantly worse long-term survival. Extracapsular LNI reflects a particularly aggressive biologic behaviour and has significant prognostic potential and should be considered for the future edition of the TNM staging system for oesophageal cancer. Disclosure of interest None Declared.