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The prognosis for oesophageal carcinoma is poor, but once distant metastases emerge the prognosis is considered hopeless. There is no consistent protocol for the early identification and aggressive management of metastases.To examine the outcome of a policy of active postoperative surveillance with aggressive treatment of confirmed metastases.A prospectively maintained database of 205 patients diagnosed with oesophageal carcinoma between 1998 and 2019 and treated with curative intent was interrogated for patients with metastases, either at diagnosis or on follow-up surveillance and treated for cure. This cohort was compared with incomplete clinical responders to neoadjuvant chemoradiotherapy (nCRT) who subsequently underwent surgery on their primary tumour. Overall survival was estimated using the Kaplan-Meier method, and the log-rank test was used to compare survival differences between groups.Of 205 patients, 11 (5.4%) had metastases treated for cure (82% male; median age 60 years; 9 adenocarcinoma and 2 squamous cell carcinomas). All had undergone neoadjuvant chemotherapy or chemoradiotherapy, followed by surgery in all but 1 case. Of the 11 patients, 4 had metastatic disease at diagnosis, of whom 3 were successfully downstaged with nCRT before definitive surgery; 2 of these 4 also developed oligometastatic recurrence and were treated with curative intent. Following definitive treatment, 7 had treatment for metachronous oligometastatic disease; 5 of whom underwent metastasectomy (adrenal × 2; lung × 2; liver × 1). The median overall survival was 10.9 years [95% confidence interval (CI): 0.7-21.0 years], which was statistically significantly longer than incomplete clinical responders undergoing surgery on the primary tumour without metastatic intervention [Metastatic oesophageal cancer represents a unique challenge, but aggressive treatment can be rewarded with impressive survival data. In view of recent advances in targeted therapies, intensive follow-up may yield a greater number of patients with curative potential and thus improved long-term survival.

OBJECTIVE: To compare overall survival of patients with a cCR undergoing active surveillance versus standard esophagectomy.SUMMARY OF BACKGROUND DATA: One-third of patients with esophageal cancer have a pathologically complete response in the resection specimen after neoadjuvant chemoradiotherapy. Active surveillance may be of benefit in patients with cCR, determined with diagnostics during response evaluations after chemoradiotherapy.METHODS: A systematic review and meta-analysis was performed comparing overall survival between patients with cCR after chemoradiotherapy undergoing active surveillance versus standard esophagectomy. Authors were contacted to supply individual patient data. Overall and progression-free survival were compared using random effects meta-analysis of randomized or propensity score matched data. Locoregional recurrence rate was assessed. The study-protocol was registered (PROSPERO: CRD42020167070).RESULTS: Seven studies were identified comprising 788 patients, of which after randomization or propensity score matching yielded 196 active surveillance and 257 standard esophagectomy patients. All authors provided individual patient data. The risk of all-cause mortality for active surveillance was 1.08 [95% confidence interval (CI): 0.62-1.87, P = 0.75] after intention-to-treat analysis and 0.93 (95% CI: 0.56-1.54, P = 0.75) after per-protocol analysis. The risk of progression or all-cause mortality for active surveillance was 1.14 (95% CI: 0.83-1.58, P = 0.36). Five-year locoregional recurrence rate during active surveillance was 40% (95% CI: 26%-59%). 95% of active surveillance patients undergoing postponed esophagectomy for locoregional recurrence had radical resection.CONCLUSIONS: Overall survival was comparable in patients with cCR after chemoradiotherapy undergoing active surveillance or standard esophagectomy. Diagnostic follow-up is mandatory in active surveillance and postponed esophagectomy should be offered to operable patients in case of locoregional recurrence.

Stenting is the management of choice for many benign and malignant oesophageal conditions and in the interest of safety stent insertion has traditionally been performed under fluoroscopic guidance. But this incurs additional expense, time, radiation risk and for the foreseeable future, an increased risk of Covid infection to patients and healthcare personnel. We describe a protocol that obviates the need for fluoroscopic guidance, relying instead on a systematic checklist to ensure safe positioning of the guidewire and the accurate positioning of the stent. The aim of this retrospective study was to review our experience of stent insertion employing a checklist system and compare our outcomes with outcomes using fluoroscopy in the literature.We performed a retrospective review of a prospectively collected dataset of all patients undergoing oesophageal stent insertion between December 2007 and October 2019. The primary end points were patient safety parameters and complications of stent insertion.Total of 163 stents were deployed of which 93 (57%) were in males and the median age was 67.9 years (25-92 years). Partially covered self-expanding metallic stents (SEMS) were used in 80% of procedures (130/163). One hundred nineteen stents (73%) were for malignant strictures and 127 (78%) were deployed for strictures in the lower third of the oesophagus. There was no stent misplacement, injury, perforation or death associated with the procedure. Vomiting was the main post-operative complication (14%). Severe odynophagia necessitated stent removal in 3 patients. Stent migration occurred in 17 (10%) procedures with a mean time to stent migration of 6.4 weeks (range 1-20 weeks).Oesophageal stent placement without fluoroscopy is safe provided that a strict checklist is adhered to. The outcomes are comparable to the results of fluoroscopic stent placement in the literature, with considerable saving in time, cost, personnel, and risks of radiation and Covid exposure.

Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease but when laparoscopic removal proves impossible the standard advice is to convert to open surgery. This jettisons the advantages of laparoscopy for a procedure which surgeons no longer perform routinely, so it may no longer be the safest practice. We hypothesised that gallbladder aspiration would be a safer alternative when laparoscopic removal is impossible. A retrospective analysis was performed of all laparoscopic cholecystectomies attempted under one surgeon’s care over 19 years, and the outcomes of gallbladder aspiration were compared with the standard conversion-to-open procedure within the same institution. Of 757 laparoscopic cholecystectomies attempted, 714 (94.3%) were successful, while 40 (5.3%) were impossible laparoscopically and underwent gallbladder aspiration. Interval cholecystectomy was later performed in 34/40 (85%). Only 3/757 (0.4%) were converted to open. No aspiration-related complications occurred and excessive bile leakage from the gallbladder was not observed. During this time 1209 laparoscopic cholecystectomies were attempted by other surgeons in the institution of which 55 (4.55%) were converted to open and 22 (40%) had procedure-associated complications. There was a significant difference in the mean (± SEM) post-operative hospital stay between laparoscopic gallbladder aspiration [3.12 (± 0.558) days] and institutional conversion-to-open cholecystectomy [9.38 (± 1.04) days] (p

Background and objectives Neoadjuvant chemoradiotherapy (nCRT) induces a pathological complete response (pCR) in 25–85% of oesophago-gastric cancer. As surgery entails morbidity and mortality risks and quality of life (QL) impairment, its avoidance in patients without residual disease is desirable. This study aimed to compare quality of life of patients with a cCR who chose surveillance with those who chose surgery. Methods Four groups of patients were studied. Group 1(n = 31) were controls; Group 2 (n = 26) had chemoradiotherapy only; Group 3 (n = 31) had oesophagectomy after nCRT; Group 4 (n = 26) had gastrectomy alone. A 33-point novel questionnaire was administered at two 3 month time points. Participants were also interviewed with a validated questionnaire. Results Mean(±sd) quality of life scores in cCR patients offered surveillance (28.9 ± 4.5) were superior to patients undergoing oesophagectomy (32.3 ± 58. p=0.042) or gastrectomy (33.19 ± 5.9, p=0.004). This result was replicated in the validated questionnaire (p=0.017). There was a trend towards increased reflux-related respiratory symptoms in the oesophagectomy group (7.3 ± 2.2 vs 6.5 ± 1.9; p=0.396) and towards early dumping (8.2 ± 1.4 vs 7.1 ± 1.; p=0.239) and vagotomy-related symptoms (1.82 ± 0.9 vs 1.4 ± 0.6; p=0.438) in the gastrectomy group. Conclusions Avoidance of surgery in cCR patients is rewarded with a superior quality of life to those undergoing surgery.

BACKGROUND Esophageal injury is a rare but potentially lethal surgical emergency. It is associated with significant morbidity and mortality because of mediastinal contamination and difficulty of access. Surgery in such septic patients exacts a heavy physiological price, mandating consideration of more conservative measures. We review our experience with transgastric drainage for esophageal perforation and high-risk anastomotic dehiscence. PATIENTS AND METHODS A select cohort of patients presenting with esophageal perforation, or complex anastomotic leaks, over 10 years were considered for transgastric drainage (TGD). A modified 36F chest drainage tube was inserted by percutaneous endoscopic gastrostomy technique, either endoscopically or at open surgery, and a negative pressure (-10 cmH2O) was applied until the leak had sealed. Endpoints include, length of stay, restoration of gastrointestinal tract continuity and mortality. RESULTS Of 14 patients treated, 10 had perforations and 4 had complex anastomotic leaks. Ten patients had drainage alone, while 4 required concomitant operative intervention. The median duration of drainage was 19.5 days. Complete restoration of gastrointestinal tract continuity was achieved in all patients. There was no procedure-related morbidity or mortality. CONCLUSION These results show that TGD is a safe and effective management strategy. We advocate its use alone or as an adjunct to operative treatment for esophageal perforation or anastomotic leaks. This is the first report of completely endoscopic TGD for esophageal perforation.

Up to 50% of patients with esophageal cancer have a pathologically complete response after neoadjuvant chemoradiotherapy (nCRT) plus surgery. An active surveillance strategy may be feasible in patients with a complete clinical response (cCR) after nCRT. The aim of this study was to perform a meta-analysis using data of individual patients that underwent active surveillance with surgery for recurrent disease versus standard surgery after nCRT. Methods A systematic search was performed in Embase, Medline, Web of Science, Scopus and Cochrane from inception to February 2020. Studies were sought that reported on overall survival and recurrence rates in patients with cCR after nCRT that underwent active surveillance versus standard surgery. Authors were contacted to supply individual patient data. Pooled hazard ratio (HR) comparing survival outcomes and distant dissemination rates (DDR) between patients with cCR undergoing active surveillance or standard surgery were estimated using a random-effect meta-analysis. Cumulative incidence of locoregional recurrences in active surveillance were assessed using a Cox Frailty model. Results Seven studies including 788 patients (256 active surveillance and 532 surgery) were identified. All authors provided anonymized patient data. Pooled two- and five-year overall-survival was 75% and 58% for active surveillance and 76% and 60% for standard surgery with a pooled HR of 1.04 (95%CI:0.73–1.49) (Figure 1). Two-years DDR was 18% and 19% for active surveillance and standard surgery, respectively (HR 1.10,95%CI:0.75–1.63). Locoregional recurrence rate necessitating esophagectomy in patients undergoing active surveillance was 24% at one year, 33% at two years and 38% at five years. Active surveillance patients undergoing postponed surgery had R0 in 91% of cases. Conclusion Overall survival is comparable in patients undergoing active surveillance with postponed surgery compared to standard surgery after neoadjuvant chemoradiation. Distant dissemination rate is also comparable between both groups. During active surveillance, local regrowths developing after two years are rare. Although these data support an active surveillance strategy, randomized trials have to be completed before an active surveillance strategy can be actively proposed to patients with esophageal cancer.

Background Sarcopenia is associated with increased morbidity and mortality in oncologic and transplant surgery. It has a high incidence in chronic inflammatory states including inflammatory bowel disease (IBD). The validity of existing data in IBD and of sarcopenia's correlation with surgical outcomes is limited. Methods We performed a systematic review to assess the correlation of sarcopenia with the requirement for surgery and surgical outcomes in patients with IBD. Observational studies of patients with IBD in whom an assessment of sarcopenic status/skeletal muscle index was undertaken, a proportion of whom proceeded to surgical management, were selected. Results A total of 5 studies with a combined 658 IBD patients met the inclusion criteria. The majority (70%) had a diagnosis of Crohn's disease. Median (range) body mass index and skeletal muscle index were reported in 4 studies and were 16.58 (13.66-22.50) kg/m2 and 44.52 (42.90-50.64) cm2/m2, respectively. Forty-two percent of IBD patients had sarcopenia. Notably, none of the studies assessed both the anatomical and functional component required for a correct assessment of sarcopenia. Three studies noted that sarcopenic IBD patients had a higher probability of requiring surgery. The rate of major complications (Clavien-Dindo grade ≥IIIa) was significantly higher in patients with sarcopenia. Improved perioperative nutrition management may mitigate the risk of complications. Conclusion Many IBD patients are young, may be malnourished, and commonly require emergent surgery. There is considerable heterogeneity in the assessment of sarcopenia. Sarcopenia is common in the IBD population and can predict the need for surgical intervention. Sarcopenia correlates with an increased rate of major postoperative complications. Improved perioperative intervention may diminish this risk. A formal assessment, screening by a dedicated IBD dietician, and preoperative physical therapy may facilitate early intervention.

Background Cholecystectomy alters bile release dynamics from pulsatile meal-stimulated to continuous, and results in retrograde duodeno-gastric bile reflux (DGR). Bile is implicated in mucosal injury after gastric surgery, but whether cholecystectomy causes esophagogastric mucosal inflammation, therefore increasing the risk of metaplasia, is unclear. Study Design This study examined whether cholecystectomy-induced DGR promotes chronic inflammatory mucosal changes of the stomach and/or the esophagogastric junction (EGJ). Four groups of patients were studied and compared with controls. A group of patients was studied before and 1 year after cholecystectomy; 2 further groups were studied long-term post-cholecystectomy (LTPC) at 5 to 10 years and 10 to 20 years. All underwent abdominal ultrasound and upper gastrointestinal endoscopy with gastric antral and EGJ biopsies, noting the presence of gastric bile pooling. Biopsy specimens were stained for Ki67 and p53 overexpression, and the bile reflux index (BRI) was calculated. Results At endoscopy, bile pooling was observed in 9 of 26 (34.6%) controls, in 8 of 25 (32%) patients pre-cholecystectomy, in 15 of 25 (60%) 1 year post-cholecystectomy patients (p = 0.047), and 23 of 29 (79.3%) LTPC patients (p = 0.001). Bile reflux index positivity at the EGJ increased from 19% of controls through 41% of LTPC patients (p = 0.032). Ki67 was overexpressed at the EGJ in 19% of controls, but in 62% of LTPC patients (p = 0.044); p53 was overexpressed at the EGJ in 19% of controls compared with 66% of LTPC patients (p = 0.001). Conclusions Duodeno-gastric bile reflux was more common in patients with gallstones than in controls, and its incidence doubled after cholecystectomy. This was associated with inflammatory changes in the gastric antrum and the EGJ, evident in most LTPC patients. Ki67 and p53 overexpression at the EGJ suggests cellular damage attributable to chronic bile exposure post-cholecystectomy, increasing the likelihood of dysplasia. Further studies are required to determine whether DGR-mediated esophageal mucosal injury is reversible or avoidable, and whether surveillance endoscopy is indicated after cholecystectomy.

Contains fulltext : 215779.pdf (Publisher’s version ) (Open Access) BACKGROUND: An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. METHODS: The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. DISCUSSION: The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. TRIAL REGISTRATION: NCT03222895 , date of registration: July 19th, 2017.

Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease but when laparoscopic removal proves impossible the standard advice is to convert to open surgery. This jettisons the advantages of laparoscopy for a procedure which surgeons no longer perform routinely, so it may no longer be the safest practice. We hypothesised that gallbladder aspiration would be a safer alternative when laparoscopic removal is impossible.A retrospective analysis was performed of all laparoscopic cholecystectomies attempted under one surgeon's care over 19 years, and the outcomes of gallbladder aspiration were compared with the standard conversion-to-open procedure within the same institution.Of 757 laparoscopic cholecystectomies attempted, 714 (94.3%) were successful, while 40 (5.3%) were impossible laparoscopically and underwent gallbladder aspiration. Interval cholecystectomy was later performed in 34/40 (85%). Only 3/757 (0.4%) were converted to open. No aspiration-related complications occurred and excessive bile leakage from the gallbladder was not observed. During this time 1209 laparoscopic cholecystectomies were attempted by other surgeons in the institution of which 55 (4.55%) were converted to open and 22 (40%) had procedure-associated complications. There was a significant difference in the mean (± SEM) post-operative hospital stay between laparoscopic gallbladder aspiration [3.12 (± 0.558) days] and institutional conversion-to-open cholecystectomy [9.38 (± 1.04) days] (p 0.001), with attendant cost savings.Laparoscopic gallbladder aspiration is a safe alternative to conversion when inflammation makes cholecystectomy impossible laparoscopically, especially in the sickest patients and for surgeons with limited open surgery experience. This approach minimises morbidity and permits laparoscopic cholecystectomy in the majority after a suitable interval or referral of predicted difficult cases to specialist hepatobiliary centres.

Hydrostatic balloon dilatation of upper gastrointestinal strictures is associated with a risk of perforation that varies with the underlying pathology and with the technique employed. We present a technique of trans-balloon visualisation of the stricture during dilatation (TBVD) that allows direct ‘real-time’ observation of the effect of dilatation on the stricture, facilitating early recognition of mucosal abruption, thereby reducing the perforation rate. We retrospectively analysed 100 consecutive patients, undergoing balloon dilatation of oesophageal strictures between 1st of January 2011 and 1st of July 2014. One hundred patients underwent 186 dilatations, with 34 having multiple procedures (mean 1.86). All had oesophageal strictures (mean diameter 8.49 mm, range 5–11 mm) and most underwent dilatation up to a maximum of 17 mm (mean 14.7 mm). Fifty-six percent were male and the average age was 62.5 years (17–89 years). Only one patient (0.5 % of all procedures) had a full-thickness perforation requiring intervention while just one further patient had a deep mucosal tear that did not require intervention. TBVD is a safe technique with a short learning curve and is one of the important factors that allow potentially difficult dilatations to be performed safely with an exceptionally low rate of adverse events of less than 1 %.

Background Acute pancreatitis is a commonly encountered emergency but accurately predicting that subset of patients who will become systemically unwell has proven difficult. Simple haematological prognostic markers, such as red cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR), could identify such patients. The aim of this study was to assess the usefulness of RDW and NLR measured on admission as predictors of mortality and intensive care (ICU) or high dependency unit (HDU) admission in patients with acute pancreatitis. Materials and methods All patient who presented to our institution with acute pancreatitis between August 2013 and August 2016 were retrospectively identified using the prospectively maintained Hospital In-Patient Enquiry (HIPE) discharge audit. Data on survival, admission to HDU or ICU, length of stay and haematological parameters including RDW and NLR on presentation to the emergency department were collected. Results A total of 185 patients with acute pancreatitis were included of which 23 (12%) patients had a RDW above the upper limit of normal (ULN), which was associated with a significantly increased likelihood of admission to ICU or HDU (RR3.5; p = 0.01); 117 (63%) patients had a NLR above 5 on presentation, which also increased the risk of ICU or HDU admission (RR 8.1; p = 0.01). Patients who had both a RDW above the ULN and a raised NLR had an increased risk of inpatient mortality (RR 9.9; p = 0.04). Conclusion RDW and NLR can identify patients at increased risk of severe acute pancreatitis on presentation to the Emergency Department.

For many years, open gastrectomy with lymphadenectomy was the gold standard treatment for gastric cancer. In recent years, however, laparoscopic assisted total gastrectomy with associated D2 lymphadenectomy has gained in popularity. It has a similar oncological outcome to open resection, but has all of the added advantages of a laparoscopic procedure, such as early mobilisation, less postoperative pain and shorter hospital stay. This article describes the operative techniques, including key procedure steps, as well as a guide for using the new OrVil device for the laparoscopic creation of the oesophago-jejunal anastomosis. A video of a laparoscopic assisted total gastrectomy is presented.

Background Neoadjuvant chemotherapy improves prognosis of patients with locally advanced gastroesophageal adenocarcinoma. The aim of this study was to identify predictors for postoperative survival following neoadjuvant therapy. These could be useful in deciding about postoperative continuation of chemotherapy. Methods This meta-analysis used IPD from RCTs comparing neoadjuvant chemotherapy with surgery alone for gastroesophageal adenocarcinoma. Trials providing IPD on age, sex, performance status, pT/N stage, resection status, overall and recurrence-free survival were included. Survival was calculated in the entire study population and subgroups stratified by supposed predictors and compared using the log-rank test. Multivariable Cox models were used to identify independent survival predictors. Results Four RCTs providing IPD from 553 patients fulfilled the inclusion criteria. (y)pT and (y)pN stage and resection status strongly predicted postoperative survival both after neoadjuvant therapy and surgery alone. Patients with R1 resection after neoadjuvant therapy survived longer than those with R1 resection after surgery alone. Patients with stage pN0 after surgery alone had better prognosis than those with ypN0 after neoadjuvant therapy. Patients with stage ypT3/4 after neoadjuvant therapy survived longer than those with stage pT3/4 after surgery alone. Multivariable regression identified resection status and (y)pN stage as predictors of survival in both groups. (y)pT stage predicted survival only after surgery alone. Conclusion After neoadjuvant therapy for gastroesophageal adenocarcinoma, survival is determined by the same factors as after surgery alone. However, ypT stage is not an independent predictor. These results can facilitate the decision about postoperative continuation of chemotherapy in pretreated patients.

Penetrating trauma—the classical presentation of disorganised crime—can pose a challenge in their management due to their complexity and unpredictability. We examined the experience of one urban unit in the management of penetrating injuries to draw conclusions pertinent to other Irish centres. A retrospective study was performed of all penetrating injuries presenting to the Emergency Department (ED) of Connolly Hospital, Dublin between January 2009 and December 2012. Information was collected from the Hospital Inpatient Enquiry database, theatre logbooks and ED records. One hundred and four patients presented with penetrating injuries in the given period. Four mortalities were recorded. Abdominal injury was recorded in 22 % of patients; 26 % had multiple injuries not involving the abdomen; 11 % had an isolated thoracic injury. Fifty-seven percent required surgery, of which 40 % required emergency or early surgical intervention. Laparotomy and laparoscopy were required in 14 and 7 %, respectively; 5 % required thoracotomy of which two had penetrating cardiac injuries, both of whom survived. Although many patients with penetrating trauma can be safely managed conservatively, our study shows that over half required surgical intervention. These data highlight the need for a trauma team in each Irish centre receiving trauma with a clear need for general surgeons on emergency on-call rotas to be experienced in trauma management. There is an urgent need to centralise the management of trauma to a limited number of designated trauma centres where expertise is available by surgeons with a special interest in trauma management.

Background Dehiscence of esophago-gastric or esophago-jejunal anastomosis and spontaneous esophageal perforation are life threatening conditions due to the likelihood of breakdown following repair and the sequelae of sepsis. No unit has a large experience in the management of these problems and many approaches are described. Negative intraluminal pressure therapy (NIPT) is a method of minimally invasive operative management described by Berrisford and colleagues (Eur J Cardio-Thoracic Surg 33;2008;742–744). Despite its success, few institutions have reported on its use. Methods We reviewed our experience with the management of complex esophageal and anastomotic leaks and identified those that failed stenting, or where the diagnosis of major clinical anastomotic leaks was delayed. In this unit NIPT is the treatment of choice for these at risk patients. NIPT involves the open or endoscopic placement of an intra-luminal drainage tube with multiple side-holes, which is placed across the esophageal defect and brought through the stomach or jejunum and through the upper abdominal wall. A 10cm negative pressure of H20 is applied and the patency of the tube is maintained by the patient orally ingesting sterile water continuously. Nutrition may be provided parenterally or jejunally. Results Eleven patients were identified who were treated with NIPT for either esophageal perforation or delayed anastomotic failure over a 7 year period. Four patients had anastomotic leaks, 4 had iatrogenic perforations (2 failed stenting and 1 delayed diagnosis) and 3 had Boerhaave's syndrome. Of the 11 patients, 8 were male. Age ranged from 19–71 years. The median duration of drain application was 19 days. For 5 of the 11 patients, NIPT was combined with some degree of formal operative intervention. Operative video footage was taken and archived where possible. Complete restoration of the GI tract continuity was achieved in all patients. There was no significant procedural morbidity and there were no mortalities. Conclusion NIPT is a minimally invasive treatment option for complex esophageal/anastomotic leaks and we advocate its use, alone or as an adjunct to surgical intervention, in the above patient cohort. We have increasingly inserted the tube successfully under sedation alone, reducing the perioperative complications of general anaesthesia. Disclosure All authors have declared no conflicts of interest.

Background Survival for esophageal cancer remains poor despite neo-adjuvant chemo-radiotherapy (nCRT) and surgical resection. The median survival for nCRT plus surgery in the CROSS trial was 48 months with a pathological complete response (pCR) rate of 29%. All pCR patients will have been clinical complete responders (cCR) and while surveillance and salvage surgery (S + SS) for cCR in rectal cancer is well investigated, it is unclear whether the outcomes are similar in esophageal cancer. As morbidity and mortality following esophagectomy is high, avoidance of surgery for predicted pCR would represent a clear advantage. Our unit offers a supported choice for cCR patients to opt for surgery or for surveillance. There is currently no literature on the cost benefit of a watch and wait policy for esophageal cancer patients with a complete clinical response. Methods We identified all cCR patients from a prospectively collected database of esophageal cancer patients offered curative treatment with nCRT from 1999 to 2017. We costed the S + SS group for whom accurate costing data was available and we matched these, according to time of follow up, to a control group of cCR who underwent surgery. Cost (from the National DRG cost manual) was calculated based on cost of surgery, ICU stay, admission length, and follow up radiological and endoscopic procedures. The data was analysed using a two-tailed, equal variance t-test. Results Of 237 patients who received nCRT, 86 had a cCR. Of these, 15 patients in the S + SS fulfilled the selection criteria with a mean follow up of 10.2 compared with 10.4 months in the control group (P = 0.925). The mean number of days in hospital was 19.2 vs. 43.2 days consecutively during the follow up period. The mean estimated cost to the HSE was €91,480 for S + SS compared with €301,280 for the controlled surgery group (P = 0.01). Conclusion This study identified a significant cost benefit for surveillance over surgery. Further studies are required to accurately identify those who cannot benefit from surgery and to assess quality of life years gained and cost per year of life are needed. Disclosure All authors have declared no conflicts of interest.

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

Background Bone marrow micrometastases are present in a high proportion of patients undergoing curative resection for esophagogastric cancer. The incorporation of preoperative systemic therapies into these patients’ treatment is widely practiced. This study investigates the effect of neoadjuvant chemoradiotherapy (CRT) on the incidence of micrometastases and the viability of detected tumor cells. Materials and methods Rib bone marrow was obtained from patients (n = 106) in three centers, who were selected for potentially curative resection. Patients received neoadjuvant CRT plus surgery (n = 55), or surgery alone (n = 51). To detect micrometastases, mononuclear cells were isolated from fresh marrow and immediately stained immunohistochemically with an anti-cytokeratin-18 antibody using the APAAP technique. Tumor cell viability was assessed by immunohistochemical staining of marrow cell cultures for cytokeratin-positive cells. Results Micrometastases were detected in fresh marrow in 42% (23/55) of patients who received neoadjuvant CRT plus surgery, and in 67% (34/51) of patients treated with surgery alone. Viable tumor cells were demonstrated in 10 of 18 marrow cultures from CRT plus surgery cases. In this patient subset, combination of results of staining fresh and cultured marrow significantly increased micromet detection to 78%. Conclusions A significant proportion of patients with esophagogastric cancer have disseminated viable tumor cells at time of surgery, irrespective of pre-operative treatment. The use of marrow culture in parallel with fresh marrow staining may increase the detection of micrometastases. The persistence of tumor cells resistant to systemic therapy may explain why these regimens fail in a majority of patients.

The role of multimodal treatment in the management of esophageal cancer is controversial. There are conflicting results from studies on the effect of neoadjuvant and/or adjuvant treatment on long-term survival. Following a search of the Medline database, the authors examine the results of randomized studies on the various treatment protocols available and discuss future therapeutic improvements.

OBJECTIVE: Gallbladder removal is associated with an increased incidence of gastroesophageal reflux, but the mechanism is unclear. Cholecystokinin (CCK) release, which causes gallbladder contraction, is inhibited by bile in the duodenum. This study investigates the effect of cholecystectomy on meal-stimulated CCK secretion. METHODS: Three groups of patients were studied. Group 1 (n = 15) were normal controls. Group 2 (n = 27) were patients with symptomatic gallstones. Group 3 (n = 25) were patients who had undergone cholecystectomy. Meal-stimulated CCK levels were measured by radioimmunoassay at defined time points for 60 min after a standard corn oil-based meal. RESULTS: Fasting CCK levels were similar in all three groups. In postcholecystectomy patients, meal-stimulated plasma CCK levels were significantly elevated compared with controls: median (range) integrated CCK values for 60 min were 116 (28–209) in controls, 123 (20–501) in gallstone patients, and 176 (63–502) after cholecystectomy. CONCLUSIONS: This study suggests that cholecystectomy causes an exaggerated meal-stimulated CCK response. Because CCK is known to relax the lower esophageal sphincter, these findings may help explain the increased incidence of gastroesophageal reflux seen after cholecystectomy.

Background: Predicting response to treatment has long been the Holy Grail of clinicians treating patients with upper gastrointestinal malignancy. The widespread use of neoadjuvant therapy for esophageal cancer has provided an added urgency to the issue and at the same time brought success a step closer because accurate response can be determined from analysis of the resected specimen. Methods: A search was undertaken of the Medline database for text references to neoadjuvant therapy, esophagus, stomach and predicting response. The references of these publications were further scanned for appropriate references in the text and reference lists. Results: Publications describing predictive markers to neoadjuvant therapy for esophageal cancer, which were most likely to be of clinical significance, were selected for inclusion in this report. Conclusions: The most reliable tissue markers of response based on analysis of pretreatment biopsy specimens include P53, Ki-67, EGFR and the most impressive serum marker for monitoring response are CYFRA 21-1 and CEA. The results, however, are inconsistent, and the markers of relatively low sensitivity and none reliably identifies individual patients who will respond.

We present a rare case of an insulin-like growth factor-2 (IGF-2)-secreting tumour of the thorax. This patient demonstrated the combination of fasting hypoglycaemia and impaired glucose tolerance on oral glucose tolerance testing, which has not been previously described in this condition. A review of the literature of IGF-2-secreting intrathoracic tumours is presented here.

The introduction of minimally invasive surgery and the use of laparoscopic techniques have significantly improved patient outcomes and have offered a new range of options for the restoration of intestinal continuity. Various reconstruction techniques have been described and various devices employed but none has been established as superior. This study evaluates our experience with, and modifications of, the orally inserted anvil (OrVil™). We conducted a prospective observational study on 72 consecutive patients who underwent OrVil™-assisted oesophago-gastric or oesophago-jejunal anastomosis between September 2010 and September 2013. We collected data including patient demographics, disease site, type of procedure, location of the anastomosis, involvement of resection margins and peri-operative complications. Seventy-two patients were included in the study. Patient ages ranged from 45 to 92 years (median ± SD = 69 ± 10 years). Total gastrectomy with Roux-en-Y anastomosis was the most-commonly performed procedure (n = 41; 57 %). R 0 resection was achieved in 67 patients (93 %). There were no Orvil™-related clinical leaks during the study period, and just two patients (2.8 %) demonstrated radiological evidence of leak, both of whom were managed conservatively. There were three in-hospital mortalities during the study period; these were unrelated to the anastomotic technique. Despite a steep learning curve, the OrVil™ device is safe and reliable. It also permits the creation of higher trans-hiatal anastomoses without resorting to thoracotomy in high-risk patients with cardia tumours. Certain shortcomings of the device, that had implications for patient safety, were identified and addressed by intra-operative modification during the study period. We commend the use of a prepared OrVil™ device, as a game changer, for upper gastrointestinal reconstruction.

Introduction: Angiogenesis is fundamental to tumour growth and vascular endothelial growth factor (VEGF) is one of the most potent proangiogenic cytokines known. We have previously demonstrated that tamoxifen reduces serum VEGF in certain cancer patients. We hypothesized that tamoxifen may attenuate the angiogenetic response to VEGF. Methods: Human dermal microvessel endothelial primary cell cultures (HMEC) were incubated with tamoxifen (1.25–5.0 μg) or vehicle. Cell proliferation was quantified using 5-bromo-2′-deoxyuridine (BrdU) labelling endothelial cell proliferation assay. The effect of oral tamoxifen (20 mg/day) on VEGF-mediated angiogenesis in vivo was assessed using a Matrigel angiogenesis assay in the Sprague–Dawley rat. Results: Tamoxifen (5.0 μg/ml) significantly reduced HMEC proliferation over 24 h when compared with cells treated with vehicle alone. Oral administration of tamoxifen in the rat (20 mg/day) significantly reduced endothelial cell proliferation and migration in response to VEGF. Conclusion: Tamoxifen (5.0 μg/ml) reduces proliferation of a VEGF-dependent endothelial cell line in vitro. In vivo, orally administered tamoxifen reduces VEGF-mediated angiogenesis in the rat. These findings indicate that tamoxifen may directly inhibit the effect of VEGF on the endothelial cell, in addition to its previously described effect of reducing serum VEGF levels. This data supports a role for tamoxifen in modulation of the VEGF-dependent angiogenic response to surgical trauma, particularly as an adjuvant therapy for VEGF-dependent tumours.

Objective: To determine the contribution of urethral and skin flora to seminal fluid cultures and the relation between bacteriospermia and seminal leukocytes. Design: Prospective study. Setting: IVF-ET unit at a university teaching hospital. Patient(s): Sixty men starting an IVF-ET program. Intervention(s): Culture of sequential first-catch urine, midstream urine, and semen samples with evaluation of seminal leukocytes. Main Outcome Measure(s): A comparison of microbes from first-catch urine, midstream urine, and semen samples and the correlations of seminal microbes, elevated leukocyte concentrations, and pregnancy. Result(s): Microorganisms were detected in 37% of first-catch urine samples, 27% of midstream urine samples, and 51% of semen samples. Most microorganisms were gram-positive microbes and were common to both urine and semen samples. Mean and median leukocyte concentrations were 0.98 × 10 6 /mL and 0.10 × 10 6 /mL, respectively. There was no correlation between seminal microbes and raised leukocytes or between leukocytospermia and/or bacteriospermia and pregnancy. Conclusion(s): Microorganisms are commonly found in insignificant quantities in the semen of asymptomatic men. The frequent isolation of gram-positive microbes common to both urine and semen and the absence of a correlation with raised leukocyte concentrations suggest that bacteriospermia most commonly represents contamination.

Introduction: Many cancer patients have undetected micrometastatic disease at first presentation which ultimately progresses. Angiogenesis—the development of an independent blood supply—is a key event in the growth of metastases. Improved understanding of the influence of angiogenesis on micrometastatic growth may lead to new therapeutic intervention. Methods: This study examines current concepts of the significance of micrometastases and the role of angiogenesis in their development and destruction. A comprehensive review of the literature on micrometastasis and angiogenesis was performed using the Medline database between 1966 and 1999. Conclusions: Advances in technology have improved our ability to diagnose metastatic disease, but micrometastases in loco-regional lymph nodes and at distant sites can only be detected by sophisticated histological techniques. While the significance of micrometastases remains controversial, there is increasing evidence that micrometastatic status provides useful prognostic information and should be part of standard staging techniques. Anti-angiogenic therapy has the potential to favourably influence management of certain cancers by manipulating a number of key events in the metastatic process.

Micrometastases within bone marrow indicate a poor prognosis. We prospectively examined micrometastases in patients undergoing resection of esophagogastric cancers for (1) prevalence in rib marrow; (2) comparative detection rates in rib and iliac crest marrow; (3) responsiveness to neoadjuvant therapy; and (4) viability and tumorigenicity.In 50 consecutive patients, marrow was obtained before manipulation of the primary tumor. Micrometastatic cells were detected by staining contaminant cytokeratin-18-positive cells. Viability and tumorigenicity were determined by culture and xenograft.Micrometastases were detected in rib marrow from 88% of patients (44 of 50). When bilateral iliac crest marrow was also obtained, micrometastases were found in 15% (4 of 27) compared with 89% (24 of 27) for ribs (P0.001). Detection rates were independent of histological type or nodal status and were similar in patients with and without neoadjuvant therapy. Metastatic cells were cultured from rib marrow of 5 of 7 patients and were tumorigenic in nude mice.Most patients undergoing resection of esophagogastric malignancies have micrometastases in rib marrow. Detection rates based on iliac crest marrow are underestimates. Hematogenous spread of metastatic cells is independent of histological type or nodal status. The metastatic cells are viable, tumorigenic, and resistant to neoadjuvant therapy.

Small cell carcinoma of the oesophagus is an uncommon malignancy. Only 272 cases have been reported to date. Inconsistency in therapeutic approaches reflects the paucity of individual experience and the unsatisfactory response to current management strategies. We report 11 cases drawn from a series of 1012 cases of oesophageal malignancy and perform a statistical analysis on treatment and survival data of 189 cases drawn from the world literature. Small cell carcinoma of the oesophagus was seen to have an incidence of 1%. Seven of 11 patients were female. A variety of therapeutic modalities were employed, and the median survival was 6.6 months. Statistical analysis of these and worldwide data showed a significant survival advantage for patients who received multimodality therapy.

Background Dysphagia is the cardinal symptom of oesophageal cancer, yet many patients present late. This study examined prospectively the interval between onset of dysphagia and treatment and identified reasons for delay. Methods Patients with histologically confirmed oesophageal carcinoma were questioned about duration of symptoms and about each step of their diagnostic work-up. Delay was estimated from date of onset of symptoms to definitive treatment. Results Median delay was 15 weeks for 78 patients with dysphagia, and 17 weeks for 22 patients with other symptoms. The most frequent cause of delay was late presentation to the family doctor (44 per cent). For patients treated with surgery alone there was a trend towards more advanced stage of disease with longer delay to treatment, but no correlation with survival (P = 0.25). Conclusion Lack of awareness of the sinister significance of dysphagia is the most important cause for delay in presentation of patients with oesophageal cancer.

Lipoma of the cord, once considered rare and insignificant, has been cast in a new light by laparoscopic pre-peritoneal surgery, with diagnostic and therapeutic implications. This study aimed to determine the incidence, significance and association of spermatic cord lipomas to inguinal hernias. A retrospective review was performed for all hernia operations carried out between January 1999 and November 2002. The incidence of cord lipomas and their relation to inguinal hernias were evaluated. There were 123 repairs performed on 111 patients, 90 of which were laparoscopic via the pre-peritoneal approach, 29 were open and 4 converted from laparoscopic to open in the early part of the series. All but two cases were male (neither female had associated lipoma of the round ligament). Twenty-six lipomas of the cord were identified with an incidence of 21%. Sixteen were associated with hernia and only 10 were pure cord lipoma, an incidence of 8%. Thirteen repairs represented recurrent hernias, two of which had pure cord lipoma, one had an associated sac. Only two lipomas were suspected clinically prior to surgery. Lipoma of the cord is a poorly recognised entity that can be present with groin symptoms and clinical findings indistinguishable from inguinal hernia. Its incidence was poorly appreciated prior to the laparoscopic era.

Background The prognosis of patients with gastroesophageal adenocarcinoma is poor. There is conflicting evidence regarding effects of preoperative chemotherapy on survival and other outcomes. Methods We conducted a meta-analysis with aggregate and individual patient data (IPD) to assess the effect of preoperative chemotherapy for gastroesophageal adenocarcinoma on survival and other outcomes. Two independent reviewers identified eligible randomised controlled trials (RCTs) comparing chemotherapy+/-radiotherapy followed by surgery with surgery alone for gastroesophageal adenocarcinoma. IPD was solicited from all trials. Meta-analyses were performed using the two stage method. Results We identified 14 RCTs (2422 patients). For eight RCTs (1049 patients; 43.3%) we obtained IPD. Preoperative chemotherapy was associated with longer overall survival (hazard ratio [HR] 0.81; 95% confidence interval [CI] 0.73-0.89; p < 0.0001). There were larger treatment effects in tumours of the gastroesophageal junction and for chemoradiotherapy compared to chemotherapy, but the tests for subgroup differences were not statistically significant. Preoperative chemotherapy was associated with longer disease-free survival, higher likelihood of R0 resection and more favourable post-treatment tumour stage, but not perioperative complications. Conclusion Preoperative chemotherapy for locoregional gastroesophageal adenocarcinoma increases survival compared to surgery alone. It should be offered to all eligible patients. There appear to be larger survival advantages in tumours of the gastroesophageal junction and for chemoradiotherapy, but these findings require prospective confirmation.

Background The time-honoured mnemonic of ‘5Fs’ is a reminder to students that patients with upper abdominal pain and who conform to a profile of ‘fair, fat, female, fertile and forty’ are likely to have cholelithiasis. We feel, however, that a most important ‘F’—that for ‘family history’—is overlooked and should be introduced to enhance the value of a useful aide memoire. Methods To assess the usefulness of each of the existing factors of a popular mnemonic, 398 patients admitted with upper abdominal pain between March 2009 and April 2010 were studied. The clinical features expressed in the cholelithiasis mnemonic in patients with sonographic evidence of cholelithiasis were compared with those of patients without. Findings In the cholelithiasis group, significantly more patients were women (150/198 (75.8%) vs 111/200 (55.5%), p30 (56/198 (28.3%) vs 19/200 (9.5%) (p Interpretation Our study found that the validated ‘students’ 5Fs’ mnemonic retains a role in clinical diagnosis of patients suspected of cholelithiasis but the factor ‘familial’ should be substituted for ‘forty’ in recognition of the role of inheritance and the changing demographics of gallstone incidence.

Oesophageal cancer usually presents with systemic disease, necessitating systemic therapy. Neo-adjuvant chemoradiotherapy improves short-term survival, but its long-term impact is disputed because of limited accrual, treatment-protocol heterogeneity and a short follow-up of randomised trials.Long-term results of two simultaneous randomised controlled trials (RCTs) comparing neo-adjuvant chemo-radiotherapy and surgery (MMT) with surgical monotherapy were examined, and the response of adenocarcinoma (AC) and squamous cell carcinoma (SCC) to identical regimens compared.Between 1990 and 1997, two RCTs were undertaken on 211 patients. Patients with AC (n=113) or SCC (n=98) were separately-randomised to identical protocols of MMT or surgical monotherapy.211 patients were followed to 206 months; 104 patients were randomised to MMT (58 AC and 46 SCC, respectively) and 107 to surgery. MMT provided a significant survival-advantage over surgical monotherapy for AC (P=0.004), SCC (P=0.01). There was a 54% relative risk-reduction in lymph-node metastasis following MMT, compared with surgery (64% versus 29%, P0.001). MMT produced a pathologic complete response (pCR) in 25% and 31% of AC and SCC, respectively. Survival advantage accrued to MMT, pCR and node-negative patients: AC pCR versus surgical monotherapy (P=0.001); residual disease following MMT versus surgical monotherapy (P=0.008); SCC pCR versus surgical monotherapy (P=0.033).A survival advantage for MMT persisted long-term in AC and was replicated in SCC. MMT produced loco-regional tumour down-staging to extinction in 25-31% of patients, potentially permitting personalised treatment in this cohort that avoids the morbidity and mortality associated with resection. Node-negative patients with residual localised disease following MMT had a survival advantage over node-negative patients following surgery alone, supporting a systemic effect on micro-metastatic disease.

Cholecystogastric fistula is a rare, life-threatening complication of cholelithiasis that presents a difficult challenge to the surgeon when it occurs in elderly and co-morbid patients. Following a case of a 68-year-old female who presented with a short history of epigastric pain and vomiting, and in whom a cholecystogastric fistula was identified on abdominal computed tomography and confirmed on upper gastrointestinal endoscopy, we performed a systematic review of the literature on the management of cholecystogastric fistula. Our patient underwent laparotomy without excision of the fistula nor cholecystectomy and had an uncomplicated post-operative course. Surgical management using an open approach remains the mainstay of treatment of cholecystogastric fistula although laparoscopic techniques are used with increasing success. Surgical closure of the fistula is not always necessary. Improved surgical techniques including the use of laparoscopic surgery have led to improved outcomes in the management of cholecystogastric fistula.

Day case surgery is the most cost-effective approach for all minor, most intermediate and some major surgery. To examine the effect of the current ‘escalation’ policy of opening the surgical day ward to A&E admissions at the expense of planned surgery. A retrospective study was carried out on all elective general surgical operations planned for January through March 2003. The number of cases cancelled and the reasons for cancellation were documented. The total number of patients booked for surgery was 836, 66.6% of which were day cases (557 patients). Overall 338 patients accounting for 40.4% of all planned cases were cancelled. Day case cancellations accounted for 68.9% of all cancellations (233 patients). Bed unavailability was the main reason due to the overflow of A&E admissions, accounting for 92% of cancelled patients and 73.8% of day ward cancellations. The cancellation of surgery creates untold hardship for patients who plan their working and family lives around the proposed operation date. Most are cancelled at less than 24 hours notice. The cost implications to the community are immense but have not been calculated. The separation of emergency and planned surgery is essential through adequate observation ward access.

Background While cancer is a disease of the elderly, these patients are under-represented in randomized trials. Esophageal cancer-management in the elderly is challenging because of the morbidity and mortality associated with surgery. Objectives We examined a strategy of neo-adjuvant chemo-radiotherapy (naCRT), followed by surgery or surveillance, in selected patients with cancer aged 70 and older. Methods A prospectively-accrued database identified 56 consecutive patients over a 90-month period, who were aged 70 years and over, presented with esophageal carcinoma and were treated with neo-adjuvant CRT (naCRT) ± surgery. Results Of 129 eligible patients, 66 (51%) received palliative measures, while 63 (49%) had curative intervention, namely 7 had surgery and 56 had naCRT ± surgery. Of these 56 patients, 33 (59%) had adenocarcinoma (AC) and 23 (41%) had squamous cell carcinoma (SCC). Twenty-five (45%) had a complete clinical response (cCR), of which 6 had immediate resection; 4 (67%) had a complete pathological response (pCR); 19 patients with a cCR declined or were unfit for surgery and underwent surveillance; of these, 3 had interval esophagectomy; 16 were not offered or declined resection. Eight (50%) have survived ≥ 3 years. Mean overall survival was 28 months for the entire cohort; 47 months for cCRs; 61 months for patients undergoing primary resection, 46 months for cCRs who did not undergo resection and 29 months for those undergoing interval resection for recurrent disease. In cCRs, surgery did not provide a survival advantage (p = 0.861). Conclusion cCR yields an overall 3-year survival of 50% without operation. As 45% of patients have a cCR to naCRT, obligatory resection in high-risk cCR patients makes little sense. With the option for salvage esophagectomy in re-emergent disease, this selective strategy is an attractive alternative for elderly patients with cancer.