Search

Neoadjuvant chemotherapy is established in the treatment of gastric adenocarcinoma. Histopathological regression may have important prognostic implications. There are little data comparing clinical outcomes of patients with gastric adenocarcinoma that received neoadjuvant treatment and those neoadjuvant naive. The aim of this study is to determine the impact of neoadjuvant chemotherapy upon prognosis of patients being treated for gastric adenocarcinoma.Consecutive patients with gastric cancer from a single center between 2007 and 2017 were evaluated. Patients were treated with either a subtotal or total gastrectomy with D2 lymphadenectomy. Stage-by-stage comparison of the extent of pathological downstaging was conducted for patients who received neoadjuvant treatment (ypTNM) and those who did not (pTNM) using the TNM eighth edition.Overall, 384 patients underwent gastrectomy, 141 patients received neoadjuvant chemotherapy, and 86 patients (58.1%) were downstaged. Downstaged patients had improved overall survival compared to patients who did not respond to neoadjuvant chemotherapy (not reported vs 66 months, P.001). Downstaging by3 stages was the strongest independent predictor of overall survival (hazard ratio: 0.17; 95% confidence interval 0.062-0.44). Overall survival was significantly better among patients in the ypTNM groups when a stage-by-stage comparison was performed with the pTNM group.Pathological stage is a more accurate predictor of prognosis compared clinical stage with downstaged patients benefiting from lower recurrence rates and improved overall survival. Patients downstaged due to neoadjuvant chemotherapy may potentially have more favorable clinical outcomes compared to stage-matched patients who did not receive this.

Adequate pain control is an important consideration to ensure patients can mobilise after surgery and to reduce pulmonary complications. This is frequently provided by a thoracic epidural, however there has been increasing use of multimodal analgesia. Minimally invasive approaches in esophagectomy may also reduce post-operative pain. The aim of this study was to compare pain control in patients after Ivor Lewis esophagectomy with thoracoscopic (TE) vs open approach using multimodal analgesia. Consecutive patients undergoing thoracoscopic or open esophagectomy for cancer between January 2015 and December 2019 were evaluated. All patients received multimodal analgesia (intrathecal diamorphine, paravertebral and rectus sheath catheters). Pain scores (at rest and on movement, graded from 0 to 10) were collected and compared between two cohorts. Length of stay and complications were also compared between the two groups. This study included 161 patients; 114 (70.8%) underwent an open esophagectomy and 47 (29.2%) underwent a thoracoscopic chest phase. Mean pain scores were significantly lower for TE only on postoperative days (POD) 0 on movement (open 2.81 versus TE 1.50, p = 0.026) and POD 3 at rest (open 1.00 versus TE 0.60, p = 0.030). Postoperative stay was comparable between groups (9 versus 8 days). There was no significant difference in the overall complication rate (64.0% versus 57.4%, p = 0.433), pulmonary complications (27.7% versus 35.1% p = 0.461) and 30-day mortality (2.6% versus 0%, p = 0.262). These results may suggest that a minimally invasive thoracoscopic approach does not provide additional analgesic benefit in comparison to open approach when multimodal analgesia is used. A clinically meaningful difference (score difference 0.9-1.6) was achieved only on POD 0. Importantly, in this cohort the open approach was not associated with inferior short-term postoperative outcomes. Future randomised controlled trials comparing minimally invasive techniques should consider employing multimodal analgesia in their design.

Prehabilitation is designed to improve patients’ functional capacity prior to operation in order to better withstand stress of surgery and therefore improve patients’ postoperative outcomes. It is not known whether prehabilitation of patients with esophagogastric adenocarcinoma (EGA) can also improve patients’ centred outcomes. The aim of this study was to assess whether prehabilitation can lead to better health-related quality of life (HRQoL) during neoadjuvant chemotherapy (NAC) treatment for EGA. Patients enrolled into a prospective home-based prehabilitation study (ChemoFit) during NAC for EGA had their HRQoL measured using validated EORTC QLQ-C30 and QLQ-OG25 questionnaires prior NAC and prior to surgery (post-NAC). ChemoFit patients were compared with historical cohort (NO-PREHAB) which did not undergo prehabilitation and which had their HRQoL assessed in the same way during identical time points. Prehabilitation consisted of daily aerobic sessions with step-count target and daily strengthening exercises, under weekly telephone supervision. Mann U Whitney test was used for statistical comparison. There were 31 patients in ChemoFit group and 24 patients in NO-PREHAB cohort. Statistically significant intergroup differences were observed for scores of global quality of life (mean score difference ChemoFit +12.9 vs NO-PREHAB -2.4, p=0.003), physical functioning (+5.8 vs -4.9, p=0.002), role functioning (1.6 vs -13.5, p=0.022) and for symptoms of fatigue (-6.6 vs 9.7, p=0.008) and nausea/vomiting (-10.2 vs 0.7, p=0.030). Patients prehabilitated within ChemoFit study achieved better scores in several HRQoL scales including global quality of life in comparison to historical cohort which did not undergo prehabilitation. These results suggest that prehabilitation of patients with EGA might lead to improvement of their HRQoL prior to operation. It is unknown whether this difference would persist after operation. It is desirable to confirm these findings within randomised controlled trial setting.

Background The role of Cardiopulmonary Exercise Testing (CPET) prior to major surgery has been an area of growing interest over the last two decades. CPET offers an objective and composite measure of physiological functional reserve, and thus can be used to identify patients at highest risk of peri-operative morbidity and mortality. Although the role of CPET has been investigated with respect to outcomes after oesophagectomy, no clear data exist into the predictive role of CPET specifically relating to gastric cancer surgery. The aim of this study was to identify CPET parameters predictive of adverse outcome in patients undergoing curative gastric resections. Methods Patients who underwent CPET followed by curative total or subtotal gastrectomy for gastric or junctional adenocarcinoma between January 2013 and December 2019 in a single high-volume centre were included in retrospective analysis. CPET variables were categorised as per cut-off values from other surgical populations (AT 34). Associations between these variables and postoperative outcomes were analysed using chi squared or Fisher’s exact test. Results There were 252 patients included in the study. Patients with VE/VCO2>34 were more likely to return to the intensive care unit (ICU) (p = 0.033) and had a higher chance of in-hospital mortality (p = 0.012). AT Conclusions Although much has been published on the importance of CPET assessment prior to major abdominal surgery, there is a paucity of literature specifically looking at its role in patients with gastric cancer. Patients with ventilatory inefficiency (VE/VCO2>34) are more likely to return to ICU or to die during hospital stay after total/subtotal gastrectomy for malignant disease. This information should play a more prominent role when assessing patients’ fitness prior to surgery.

Background Lymph node involvement is a key prognostic indicator in gastric adenocarcinoma. Little is known of the impact of extracapsular lymph node involvement (LNI) upon the prognosis of patients undergoing curative resection of gastric cancer. The aim of this study was to assess the incidence and prognostic significance of extracapsular LNI in patients undergoing a gastrectomy for gastric adenocarcinoma. Methods Consecutive patients who underwent a subtotal or total gastrectomy with curative intent for adenocarcinoma of the stomach or gastro-oesophageal junction in a single, high-volume U.K. centre between 2010 and 2018 were identified from contemporaneously maintained database. Patients with a pN0 status on final histology and those who died in-hospital were excluded from analysis. Factors associated with survival were studied with univariable and multivariable cox regression analysis. A p value of Results The study included 235 patients. A median (IQR) of 32 (24-43) lymph nodes were resected and median (IQR) 4 (1-9) lymph nodes were positive. Of them, extracapsular LNI was identified in 123 (52%) of patients. Factors associated with survival on univariable analysis were R1 resection (p = 0.001), p/ypT stage (p Conclusions Extracapsular LNI is associated with poor prognosis among patients undergoing a curative gastrectomy. However, it is not an independent predictor of survival among this patient population.

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 Sarcopenia characterised as a loss of muscle mass and function is prevalent in cancer populations. It is known to occur in patients receiving neoadjuvant treatment and is associated with poorer outcomes. Thus, minimizing sarcopenia may lead to improved patient prognosis. It has been suggested that exercise can reverse and prevent sarcopenia. Little is known as to whether prehabilitation as an intervention to enhance patients’ functional capacity prior to surgery can lead to sarcopenia prevention. Methods Patients enrolled into a prospective prehabilitation study (ChemoFit) during neoadjuvant chemotherapy (NAC) for oesophagogastric adenocarcinoma (OGA) had their radiological sarcopenia measured before and after neoadjuvant chemotherapy (NAC). Radiological sarcopenia and lean body mass (LBM) were measured from computed tomography scans at the level of the L3 vertebra. ChemoFit patients were compared with an historical cohort (NO-PREHAB) which did not undergo prehabilitation and which had their radiological sarcopenia evaluated prospectively prior to and after NAC for OGA. Results Patients in the ChemoFit group were younger compared to the NO-PREHAB group (median age 70 vs 65, p = 0.04). Otherwise there were no differences in gender, BMI, smoking status, comorbidities, tumour location and clinical stage of the disease. Radiological sarcopenia was present prior to NAC in 17/36 (47%) which increased to 26/36 (72%) after NAC amongst ChemoFit patients. Sarcopenia prior to NAC in the NO-PREHAB cohort was 12/28 (43%) which increased to 16/28 (57%) post NAC. Intergroup difference (p = 0.291). Median (IQR) ΔLBM at two time points was in ChemoFit -2.6kg (-5.2;-0.6) and in NO-PREHAB -3.1kg (-4.7;-1.0) (p = 0.730). Conclusions Radiological sarcopenia increased in both groups during NAC for OGA. Prehabilitation did not prevent this from happening. Other strategies must be explored in order to mitigate against sarcopenia.

Background Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive oesophagectomy (MIO) is variable and can impact on patient outcomes. The aim of this study was to review the current evidence on learning curves in MIO and identify which parameters are used for benchmarking. Methods A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used. Results Twenty-nine studies comprising 3741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid and total MIO, 6 studies reported robotic assisted MIO (RAMIE) alone and 1 study evaluated both RAMIE and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity and blood loss also frequently used. Learning curves were found to plateau at 7-60 cases for thoracoscopic esophagectomy, 12-175 cases for total and thoracoscopic/hybrid esophagectomy and 9-85 cases for RAMIE. Conclusions Multiple parameters are employed to gauge MIO learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be utilised to ensure best patient outcomes and required length of proctoring.

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 Covid-19 has had a devastating global impact and resulted in over 4.4 million directly attributed deaths. The UK entered lockdown in March 2020, redistributing its medical workforce and resources. Early estimations suggested at least 4700 extra cancer deaths at 5 years if there was a 3-month delay to surgery. Delays to diagnosis and treatment for osophagogastric (OG) cancers can be particularly detrimental to survival. The aim of this study is to assess the impact of Covid-19 on new cancer referrals to a centralised UK OG cancer centre, including presentation, decision making and treatment. Methods Patients with OG cancer referred to a tertiary, high-volume centre between March 2019 and March 2021 were reviewed. Patients were stratified into Pre-covid (March 2019-March 2020) and Covid (March 2020-2021) cohorts. Number of new referrals, clinical stage, treatment decision, and time to treatment were compared for gastric adenocarcinoma (GA), oesophagogastric-junction adenocarcinoma (OGJA), oesophageal adenocarcinoma (OA) and oesophageal SCC (OSCC). Results There was an 11% reduction in new cancer referrals (485 vs 431). GA, OGJA and OA did not have significant change in treatment intent, although there was a significant increase in the decision for definitive non-surgical treatment of OA (P = 0.046). GA and OA patients had a small, but significant increase in mean clinical stage at presentation (P Conclusions This high-volume centre has seen a reduction in new cancer referrals since the first UK lockdown. This was associated with a small, but significant, increase in clinical stage of GA and OA at presentation. This may represent an early indication of excess oesophagogastric cancer deaths due to the impact of Covid-19. This data also confirms initial results showing that oncological decisions were not compromised, although Covid-19 remains a dynamic challenge.

Background Oesophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes within major surgery. Variables derived from CPET have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing oesophagectomy is associated with long-term survival. The aim of this study was to evaluate whether any of the cardiopulmonary exercise testing (CPET) variables that are routinely derived in patients with oesophageal cancer may aid in predicting long-term survival after oesophagectomy. Methods Patients undergoing CPET followed by trans-thoracic oesophagectomy for oesophageal cancer with curative intent between January 2013 and January 2017 from single high-volume centre were retrospectively analysed. The relationship between predictive co-variables including CPET variables, and survival was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was conducted to find cut-off values for CPET variables predictive of 3-year survival. Results A total of 313 patients were analyzed. The ventilatory equivalent for carbon dioxide (VE/VCO2) at anaerobic threshold was the only CPET variable independently predictive of long-term survival in multivariable analysis (HR 1.049, 95% CI 1.011-1.088, p = 0.011). Pathological stage III and IV disease was the other co-variable found to be independently predictive of survival. ROC analysis of the VE/VCO2 failed to demonstrate a predictive cut-off value of 3-year survival (AUC=0.564, 95% CI 0.499-0.629, p = 0.056). Conclusions A high VE/VCO2 before oesophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for consideration when counselling patients.

Esophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes of major surgery. Variables derived from cardiopulmonary exercise testing (CPET) have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing esophagectomy is associated with long-term survival. This study aimed to evaluate whether any of the CPET variables routinely derived from patients with esophageal cancer may aid in predicting long-term survival after esophagectomy.Patients undergoing CPET followed by trans-thoracic esophagectomy for esophageal cancer with curative intent between January 2013 and January 2017 from single high-volume center were retrospectively analyzed. The relationship between predictive co-variables, including CPET variables and survival, was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was performed to find cutoff values for CPET variables predictive of 3-year survival.The study analyzed 313 patients. The ventilatory equivalent for carbon dioxide (VE/VCOA high VE/VCO

Purpose The progressive loss of skeletal muscle and function (known as sarcopenia) has been shown to be associated with various adverse outcome measures. Sophisticated measurements of body composition are increasingly being incorporated into research studies to stratify patients into those with or without sarcopenia, monitor treatment effects, and predict complications. A typical approach is to select axial image(s) at the mid-lumbar level and use semi-automated software to identify and quantify the skeletal muscle area. This area is then used to estimate whole-body parameters. This approach is somewhat subjective, and in this study we investigate its reproducibility, both within and between observers. Materials and methods Repeated muscle measurements were performed on a cohort of 29 patients by 3 radiologists, to examine their intra- and interobserver reproducibility. Results and discussion Mean muscle area for the cohort was 156 cm2, with a wide range (98 – 261 cm2). There was good intraobserver agreement between measurements, with a mean absolute difference between repeated measurements on the same patient of 0.98 cm2, and a measurement variability of 2.92 cm2. Much of the variability was shown to be due to the choice of a different slice when performing the repeated measurement. Averaging two slices provided a small but non-significant improvement in comparison to the single slice approach. Interobserver results showed good agreement, though there was a small bias for one observer, who measured slightly larger volumes compared to the other two. We conclude that the approach described provides reproducible skeletal muscle area measurements, and offer three specific recommendations to minimise variability.

s / International Journal of Surgery 8 (2010) 501–578 548 Methods: Questionnaires were distributed to Plastics and Orthopaedics specialist trainees during regional teaching. They were asked about their experience of fasciotomies and to illustrate surgical approaches. Results were compared to the joint guidelines published by BAPRAS/BOA. Results: A total of 36 trainees completed the questionnaires, 19 in Plastics surgery and 17 in Orthopaedics. 22% of trainees had never assisted in fasciotomies. The majority of trainees had little or no clinical experience with fasciotomies, with only 33% amongst both specialities having performed fasciotomies. Only 47% demonstrated knowledge of appropriate planes of dissection. Over 50% of trainees in Plastics surgery and 70% in Orthopaedic surgery were not familiar with safe techniques for leg Fasciotomy as recommended by the guidelines. Conclusion: With the reduction of training hours, special attention needs to be granted to areas of limited exposure. This audit highlights the need for training adjuncts such as, cadaveric workshops and audiovisual seminars in order to cover shortfalls of current training. LAPAROSCOPIC ANTI-REFLUX SURGERY IMPROVES DAYTIME SOMNOLENCE Maziar Navidi, Michael Booth. Royal Berkshire Hospital NHS Foundation Trust Aims: To establish if laparoscopic anti-reflux surgery (LARS) improves daytime somnolence. Methods: Prospective analysis of pre and post operative Epworth Sleepiness Score (ESS) in twenty consecutive patients undergoing LARS in an Upper GI Unit in a six months period. The questionnaire asked subjects to rate their probability of falling asleep on a scale of increasing probability from 0 to 3 in eight different situations. The scores for the eight questions were added to obtain a single number. A number in the range 0–9 is considered to be normal while a number in the range 10–24 is considered to indicate that specialist medical advice should be recommended. Results: ESS scores pre and six months post operatively were analysed using a Paired ttest. A preoperative mean of 11.26 (on a scale of 0-24) was noted, the post operative mean was noted to be at 7.63. Application of Paired– t test indicated a p