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Delayed gastric emptying (DGE) is common after an Ivor Lewis gastro-esophagectomy (ILGO). The risk of a dilated conduit is the much-feared anastomotic leak. Therefore, prompt management of DGE is required. However, the pathophysiology of DGE is unclear. We proposed that post-ILGO patients with/without DGE have different gut hormone profiles (GHP). Consecutive patients undergoing an ILGO from 1 December 2017 to 31 November 2019 were recruited. Blood sampling was conducted on either day 4, 5, or 6 with baseline sample taken prior to a 193-kcal meal and after every 30 minutes for 2 hours. If patients received pyloric dilatation, a repeat profile was performed post-dilatation and were designated as had DGE. Analyses were conducted on the following groups: patient without dilatation (non-dilated) versus dilatation (dilated); and pre-dilatation versus post-dilatation. Gut hormone profiles analyzed were glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) using radioimmunoassay. Of 65 patients, 24 (36.9%) had dilatation and 41 (63.1%) did not. For the non-dilated and dilated groups, there were no differences in day 4, 5, or 6 GLP-1 (P = 0.499) (95% confidence interval for non-dilated [2822.64, 4416.40] and dilated [2519.91, 3162.32]). However, PYY levels were raised in the non-dilated group (P = 0.021) (95% confidence interval for non-dilated [1620.38, 3005.75] and dilated [821.53, 1606.18]). Additionally, after pyloric dilatation, paired analysis showed no differences in GLP-1, but PYY levels were different at all time points and had an exaggerated post-prandial response. We conclude that DGE is associated with an obtunded PYY response. However, the exact nature of the association is not yet established., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40 units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken., (© The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life., Methods and Analysis: We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery., Ethics and Dissemination: This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal., Trial Registration Number: ISRCTN10386621., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Aim: To provide a longitudinal analysis of the direct healthcare costs of providing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery service in the context of a randomised control trial (RCT) of obese patients with type 2 diabetes in Waitemata District Health Board, Auckland, New Zealand., Methods: The Waitemata District Health Board costing system was used to calculate costs in New Zealand Dollars (NZD) associated with all pre- and post-operative hospital clinic visits, peri-operative care, hospitalisations and medication costs up to one year after bariatric surgery. Healthcare costs of medications, laboratory investigations and hospital clinic visits for one year prior to enrolment into the RCT were also calculated., Results: One hundred and fourteen patients were randomised to undergo laparoscopic sleeve gastrectomy (LSG, n=58) or laparoscopic Roux en Y gastric bypass (LRYGB, n=56). Total costs one year pre-enrolment was $203,926 for all patients (mean $1,789 per patient). Total cost of surgery was $1,208,005 (mean $9,131 per LSG patient and mean $12,456 per LRYGB patient). Total cost one year post-operatively was $542,656 (mean $4,760 per patient). The total medication cost reduced from $118,993.72(mean $1,044 per patient) to $31,304.93 (mean $274.60 per patient), p<0.005. The largest cost reduction was seen with annual diabetic medications reducing from $110,115.78(mean $965.93 per patient) to $7,237.85 (mean $63.48 per patient), p<0.005., Conclusions: Among patients with type 2 diabetes and morbid obesity undergoing LSG and LRYGB, health service costs were greater in the year after surgery than in the year before, although prescription costs were lower post-operatively. There was no significant difference in reduction in prescription cost by surgical procedure at 12 months. However, the LRYGB surgery was more expensive than LSG, primarily because of the longer operative time required.

Aims: The duodenal switch (DS) has now established itself as an effective, durable and safe bariatric procedure. We present our initial experience on 60 patients from May 2008 to November 2012., Methods: Retrospective case series from a prospective database. 94.8% follow-up over 4 years., Results: 45 patients have completed 1-year follow-up and 28 patients completed 2-year follow-up. The mean initial body mass index (BMI) was 52.8 kg/m(2) (range 40=66 kg/m(2)). The excess weight loss has been 69.5% at 1 year (n=45) and 73.1% at 2 years (n=28) respectively. The mean hospital stay is 5.08 days (range 3-18). The range of bowel motions at 1 year is one to two movements per day. Comorbidity resolution rates were 95% (n=18) for diabetes, 100% (n=9) for obstructive sleep apnoea, 72% (18/25) or hypertension, and 92% (33/36) or dyslipidaemia. One death from liver failure occurred 9 months following surgery resulting from poor compliance with follow-up and intake of multivitamins., Conclusion: In our short-term analysis DS appears to be very efficient in terms of cure rate for morbid obesity and its comorbidities. In terms of risk/benefit DS has appeared safe with adherence to the appropriate follow-up regimen.

Introduction: Recent advances in electronic nose technology, and successful clinical applications, are facilitating the development of new methods for rapid, bedside diagnosis of disease. There is a real clinical need for such new diagnostic tools in otolaryngology., Materials and Methods: We present a critical review of recent advances in electronic nose technology and current applications in otolaryngology., Results: The literature reports evidence of accurate diagnosis of common otolaryngological conditions such as sinusitis (acute and chronic), chronic suppurative otitis media, otitis externa and nasal vestibulitis. A significant recent development is the successful identification of biofilm-producing versus non-biofilm-producing pseudomonas and staphylococcus species., Conclusion: Electronic nose technology holds significant potential for enabling rapid, non-invasive, bedside diagnosis of otolaryngological disease.

Background: The aim was to assess healing in patients with mixed arterial and venous leg ulcers after protocol-driven treatment in a specialist leg ulcer clinic., Methods: The study included consecutive patients referred with leg ulceration and venous reflux over 6 years. Legs without arterial disease (ankle : brachial pressure index (ABPI) above 0.85) were treated with multilayer compression bandaging and patients with severe disease (ABPI 0.5 or less) were considered for immediate revascularization. Those with moderate arterial compromise (ABPI above 0.5 up to 0.85) were initially managed with supervised modified compression and considered for revascularization if their ulcer did not heal. Healing rates were determined using life-table analysis., Results: Of 2011 ulcerated legs, 1416 (70.4 per cent) had venous reflux. Of these 1416, 193 (13.6 per cent) had moderate and 31 (2.2 per cent) had severe arterial disease. Healing rates by 36 weeks were 87, 68 and 53 per cent for legs with insignificant, moderate and severe arterial disease respectively (P < 0.001). Seventeen legs with moderate and 15 with severe arterial disease were revascularized. Of these, ulcers healed in four legs with moderate and seven with severe disease within 36 weeks of revascularization (P = 0.270). Combined 30-day mortality for revascularization was 6.5 per cent., Conclusion: A protocol including supervised modified compression and selective revascularization achieved good healing rates for mixed arterial and venous leg ulceration., (Copyright (c) 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)