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

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

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

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

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

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

Summary Background Screening for Barrett's oesophagus relies on endoscopy, which is invasive and few who undergo the procedure are found to have the condition. We aimed to use machine learning techniques to develop and externally validate a simple risk prediction panel to screen individuals for Barrett's oesophagus. Methods In this prospective study, machine learning risk prediction in Barrett's oesophagus (MARK-BE), we used data from two case-control studies, BEST2 and BOOST, to compile training and validation datasets. From the BEST2 study, we analysed questionnaires from 1299 patients, of whom 880 (67·7%) had Barrett's oesophagus, including 40 with invasive oesophageal adenocarcinoma, and 419 (32·3%) were controls. We randomly split (6:4) the cohort using a computer algorithm into a training dataset of 776 patients and a testing dataset of 523 patients. We compiled an external validation cohort from the BOOST study, which included 398 patients, comprising 198 patients with Barrett's oesophagus (23 with oesophageal adenocarcinoma) and 200 controls. We identified independently important diagnostic features of Barrett's oesophagus using the machine learning techniques information gain and correlation-based feature selection. We assessed multiple classification tools to create a multivariable risk prediction model. Internal validation of the model using the BEST2 testing dataset was followed by external validation using the BOOST external validation dataset. From these data we created a prediction panel to identify at-risk individuals. Findings The BEST2 study included 40 diagnostic features. Of these, 19 added information gain but after correlation-based feature selection only eight showed independent diagnostic value including age, sex, cigarette smoking, waist circumference, frequency of stomach pain, duration of heartburn and acidic taste, and taking antireflux medication, of which all were associated with increased risk of Barrett's oesophagus, except frequency of stomach pain, with was inversely associated in a case-control population. Logistic regression offered the highest prediction quality with an area under the receiver-operator curve (AUC) of 0·87 (95% CI 0·84–0·90; sensitivity set at 90%; specificity of 68%). In the testing dataset, AUC was 0·86 (0·83–0·89; sensitivity set at 90%; specificity of 65%). In the external validation dataset, the AUC was 0·81 (0·74–0·84; sensitivity set at 90%; specificity of 58%). Interpretation Our diagnostic model offers valid predictions of diagnosis of Barrett's oesophagus in patients with symptomatic gastro-oesophageal reflux disease, assisting in identifying who should go forward to invasive confirmatory testing. Our predictive panel suggests that overweight men who have been taking antireflux medication for a long time might merit particular consideration for further testing. Our risk prediction panel is quick and simple to administer but will need further calibration and validation in a prospective study in primary care. Funding Charles Wolfson Charitable Trust and Guts UK.

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

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

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

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

This paper describes the development and use of creative methods to engage young people experiencing psychosis in co-creation of an online resource to support their education and wellbeing....

This case study presents the first project undertaken in a recent in-hospital design collaboration – the Design for Health and Wellbeing Lab (DHW Lab). Specifically, we explore some of the challenges and opportunities associated with designing a journey map for the Adult Emergency Department, the DHW Lab's first opportunity to put co-design into practice. The intention and outcome of this project was as much about designing a journey map prototype as it was about building the interdisciplinary relationships that would help enable future successful design-led collaborations. As such, the notion of prototyping was applied to both generate artefacts to communicate care pathways to patients and families, as well as a way to build and test collaborative relationships between designers and clinical staff. The outcomes of the project resulted in new products to help patients and families negotiate a complex emergency department as well as gaining insight into how to bring people from different background...

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

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

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

One of the strengths, contemporaries argued, of Britain’s pre-NHS voluntary hospital system was that, unlike the monolith that replaced it, its provision was organically guided by, and responsive to, the direct needs of the community it served. The hospital was not simply a place of medicine but an active and symbiotic cultural site, where local people came together to further joint needs; a place of overarching pride and attachment. Yet the relationship between the community and hospital was set to change as working-class payments increased as a proportion of hospital income, so that financial costs were now more broadly shared across the classes. Did then local people truly come to view the hospital service as belonging to them — as ‘ours’ — gifted through their various fundraising and locally organized insurance contributions? Or was this more rhetoric, provided by those appealing for funds and resisting state intervention?

Background Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery. Methods Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation. Results Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204). Conclusion Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. Registration number: ISRCTN43730758 (http://www.controlled-trials.com).

Background Following a diagnosis of oesophageal cancer UICC TNM staging guides treatment and informs prognosis. There is recognised variance between clinical staging (cTNM) and post-operative pathological staging (pTNM). T3N3 oesophageal cancers have a 5-year survival of less than 25% in most studies; given the morbidity associated with radical treatment these cancers may not be considered curable. Methods A database of patients treated in a high volume UK tertiary referral centre was interrogated for all cT3N3M0 patients. Demographics, pathological stage and outcomes were recorded. Results From 2011 to 2016 34 patients met the inclusion criteria of cT3N3M0 oesophageal cancer. 11 patients had squamous cell carcinoma, the remainder adenocarcinoma. Median age was 65. Predicted overall survival at two years was 71% with a median overall survival of 54 months. 29 patients had neoadjuvant chemotherapy. All patients had an R0 resection. In 15% of patients clinical stage equated to pathological stage, 9% were ’understaged’, 76% had a better prognostic pathological stage. Conclusion Staging is considered important to allow treatment to be tailored to the individual patient. Identifying an unfavourable clinical stage may prevent inappropriate treatment, but may disadvantage patients who are erroneously ‘overstaged’. This study highlights variance between pre-treatment clinical staging and post-operative pathological staging. Care should be taken when making treatment decisions and counselling patients who have a poor prognostic clinical stage. Disclosure All authors have declared no conflicts of interest.

Background The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre. Methods Between October 1993 and May 2007, 51 consecutive patients with spontaneous oesophageal rupture were evaluated with contrast radiology and flexible endoscopy. Patients with limited contamination who fulfilled specific criteria were managed by a non-operative approach, whereas the remainder underwent thoracotomy. Results The median time to diagnosis was 24 (range 4–604) h. Initial diagnosis was by contrast swallow in 18 of 24 patients, computed tomography in 15 of 17 and endoscopy in 18 of 18. There were no deaths among 17 patients who were managed non-operatively with targeted drainage, intravenous antimicrobials, nasogastric decompression and enteral nutrition. Of 31 patients who underwent primary thoracotomy and oesophageal repair (over a Τ tube in 29), 11 died in hospital. Three patients could not be resuscitated adequately and did not have surgical intervention. Conclusion Spontaneous oesophageal rupture represents a spectrum of disease. Accurate radiological and endoscopic evaluation can identify those suitable for radical non-operative treatment and those who require thoracotomy.

Background About 10 per cent of patients undergoing radical oesophagectomy for transmural (T3) carcinoma with lymph node involvement (N1) develop symptomatic bone metastases within 12 months of surgery. The aim of this study was to evaluate the introduction of targeted preoperative bone scintigraphy. Methods Of 790 patients with oesophageal carcinoma staged between December 2000 and December 2004, 189 were eligible for potentially curative treatment. 99mTc-labelled hydroxymethylene diphosphonate bone scintigraphy was performed in those with stage T3 N1 disease (identified by computed tomography and endoscopic ultrasonography) who were suitable for radical treatment. Results A total of 115 patients had bone scintigraphy. The histological diagnosis was adenocarcinoma in 82 patients and squamous cell carcinoma in 33. Bone scintigraphy was normal or showed degenerative changes in 93 patients, and abnormal requiring further investigation in 22. Plain radiography, magnetic resonance imaging and biopsy confirmed the presence of bone metastases in 11 patients (9·6 per cent). Conclusion Bone is frequently the first site of identifiable distant metastatic spread, and bone scintigraphy is recommended to exclude metastatic disease before radical treatment of advanced oesophageal carcinoma.

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

Background The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma. Methods Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of 99mTc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld γ probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases. Results SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P < 0·001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P < 0·001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0·018), radioactive uptake (P < 0·001) and malignant nodes (P = 0·004) in the mediastinum than gastric cardia tumours. Conclusion The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.

Background The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation. Methods Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy. Results Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak. Conclusion There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Background The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis. Methods Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy. Results Nineteen patients (6·5 per cent) developed a proven mediastinal leak at a median of 8 (range 3–30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5–8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died. Conclusion Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.

Introduction: Peri-operative allogeneic blood transfusion may exert an immunomodulatory effect and has been associated with early recurrence and decreased survival following resection for several gastro-intestinal malignancies. The aim of this study was to evaluate the prognostic influence of transfusion requirements following radical oesophagectomy for cancer. Methods: A consecutive series of 235 patients undergoing subtotal oesophagectomy with two-field lymphadenectomy in a single centre from April 1990 to June 1999 were studied. Results: The median age was 64 years (30–79) with a male to female ratio of 3:1. The predominant histological subtype was adenocarcinoma (n=154) compared to squamous carcinoma (n=81). To avoid the influence of surgical complications data were excluded from the 5.5% of patients suffering in-hospital mortality. In the remaining patients, median blood loss was 900 ml (200–5500) with 46% (103/222) requiring transfusion (median 3 units, range 2–21). Median survival of non-transfused patients was 36 months compared to only 19 months for those receiving transfusion (log-rank=4.44; 1 df, P=0.0352). Non-transfused patients had significantly higher 2 and 5-year survival rates of 62% and 41% respectively in contrast to only 40% and 25% in those receiving blood transfusion. Even after stratification of results according to disease stage or the presence of major complications, survival was significantly worse in those receiving transfusion. Multivariate analysis demonstrated that in addition to nodal status, >4 units transfusion was an independent prognostic indicator.Conclusion: Post-operative transfusion is associated with a significantly worse prognosis following radical oesophagectomy. Meticulous haemostasis and avoidance of unnecessary transfusion may prove oncologically beneficial.

Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (χ2 = 25.1; P < 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy. © 1999 Cancer Research Campaign

Gastrectomy with extended lymphadenectomy is the advocated treatment in Japan for patients with "curable" stomach cancer. Attempts in units elsewhere adopting this approach failed to show any survival advantage, and the high operative mortality has prevented global acceptance of the operation. This study examines the safety and efficacy of radical gastrectomy in a Far East center outside Japan.A consecutive series of 121 patients with gastric cancer who fulfilled criteria for radical surgery had total gastrectomy with extended lymphadenectomy equivalent to D3 dissection over a 6-year period in a single unit.The operation carried a morbidity of 50%, with a perioperative mortality of 5%. Survival was best predicted by tumor stage: 5-year survival for patients with intact gastric serosa was 64%, versus 10% for those with serosal penetration (p0.001). The majority of documented metastases occurred by transperitoneal route in serosa-positive patients, but via the hematogenous mechanisms in those who were serosa-negative.Radical gastrectomy with extended lymphadenectomy carries high operative morbidity. Increased mortality occurred because of loco-regional recurrence in patients with T3/T4 diseases. Novel approaches including neoadjuvant treatment or regional therapy should be explored.

A plea not to dilate

Pathological appearance of the stomach after endoscopic mucosal resection for early gastric cancer S. Kundu, D. Karat, J. Wayman, N. Hayes, S. M. Griffin, Oesophago-Gastric Cancer Unit, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK Authors' reply: D. Korenaga, Department of Surgery, Fukuoka Dental College Hospital, 2-15-1 Tamura, Sawara-ku, Fukuoka 814-01, Japan Hereditary breast cancer Reply to letter published in previous issue (Br J Surg 1998; 85: 570–1): A. Hill, E. McDermott, N. O'Higgins, Department of Surgery, University College Dublin, St Vincent's Hospital, Elm Park, Dublin 4, Ireland Effect of a no-conversion policy on patient outcome following laparoscopic cholecystectomy M. D. Barber, P. C. Bornman, O. J. Garden, University Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK Authors' reply: P. J. O'Dwyer, Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK Correlation between blood loss and inferior vena caval pressure during liver resection P. B. S. Lai, C. K. Leow, W. Y. Lau, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong and P. T. Chui, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Dynamic graciloplasty for severe anal incontinence A. J. P. Eccersley, N. S. Williams, Academic Department of Surgery, The Royal London Hospital, Whitechapel, London E1 1BB, UK Authors' reply: J. Christiansen, O. Rasmussen, Department of Surgery, Herlev Hospital, University of Copenhagen, 75 Herlev Ringvej, DK 2730 Herlev, Denmark ‘Routine’ pathological examination of the gallbladder is a futile exercise Letter 1: K. S. Zayyan, D. P. Sellu, Surgical Sciences Unit, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK Letter 2: R. Y. Ball, Department of Histopathology/Cytopathology, Norfolk and Norwich Hospital, Brunswick Road, Norwich NR1 3SR, UK Letter 3 D. J. Bowrey, G. J. Morris-Stiff, B. I. Rees, University Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF4 4XN, UK Authors' reply: J. K. C. Huang, University Department of Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK and H. W. Taylor, Department of Surgery, Basildon Hospital, Nethermayne, Basildon SS16 5NL, UK Activated protein C resistance: the commonest hereditary hypercoagulation disorder Letter 1: I. Khogali, G. P. Summerfield, A. Mudawi, Departments of Haematology and Surgery, Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK Letter 2: S. Sulaiman-Shoab, Department of Surgery, University College London Medical School, First Floor Jules Thorne Building, Middlesex Hospital, London W1N 8AA, UK Authors' reply: K. Schuster, D. Jentschura, Department of Surgery, Klinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Strasse 1–3, 68135 Mannheim, Germany Laparoscopic stoma formation for faecal diversion R. E. K. Marshall, J. F. McPartlin, Department of Colorectal Surgery, William Harvey Hospital, Ashford TN24 0LZ, UK Authors' reply: J. W. Lumley, R. W. Stitz, Wesley Medical Centre, 24/40 Chasely Street, Auchenflower 4066, Brisbane, Australia Lateral rectal ligaments contain important nerves J.-T. Liang, K.-J. Chang, S.-M. Wang, Department of Colorectal Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan Authors' reply J. Rutegård for the authors, Department of Surgery, Örnsköldsvik Hospital, S891 89 Örnsköldsvik, Sweden Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies Letter 1: L. S. Jensen, Department of Surgical Gastroenterology, Aarhus University Hospital, 8000 Aarhus C, Denmark Letter 2: N. Blumberg, Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Box 608, Rochester, New York 14642, USA Authors' reply: F. A. McAlister, Divisions of General Internal Medicine and Clinical Epidemiology, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Canada

In a prospective study of 69 patients being treated for oesophageal carcinoma, quality of life was assessed with the Rotterdam Symptom Checklist, a dysphagia score and an activities of daily living questionnaire. Significant correlations were found between the results of the Rotterdam Symptom Checklist, the dysphagia score and most aspects of the activities of daily living questionnaire. Eighteen patients underwent surgery, 43 radiotherapy or intubation, and eight a combination of surgery and other therapy. Patients undergoing surgery were significantly younger and had better scores in all parameters examined before operation, including significantly better scores in ‘knowledge and communication’ and ‘mobility and fatigue’. The dysphagia score fell significantly after intervention both in patients undergoing surgery alone and in those receiving palliative therapy. The activities of daily living questionnaire showed significant improvements in two parameters in the surgical group (‘self-care’ and ‘eating and drinking’) and in none of the parameters assessed in the palliation group in 16 weeks. Quality-of-life assessment is useful in assessing quality of care and patient well-being after the diagnosis and treatment of oesophageal carcinoma.

Surgery has been the mainstay of treatment for spontaneous full-thickness rupture of the esophagus for the last 50 years. In an acute presentation with contamination of the mediastinal or pleural cavities, this remains the definitive course of action. However, the management when diagnosis has been delayed is more contentious. This is a description of a novel approach with a combined percutaneousendoscopic technique that was used in 2 such cases.

Nausea and vomiting in patients with advanced gastric malignancy and mechanical obstruction are distressing and difficult to manage. We describe a patient with linitis plastica and gastric stasis who was treated with a percutaneous endoscopic duodenostomy as the stomach could not be used for percutaneous endoscopic gastrostomy (PEG) formation. A ConfloTM PEG tube was inserted into the second part of the duodenum using the Ponsky–Gauderer technique without complication. The patient experienced excellent symptomatic relief and tolerated enteral nutrition extremely well, regaining some weight. This manoeuvre can produce effective symptom palliation allowing the patient to be managed at home during the terminal phase of their illness.

Background Endoscopic ultrasonography (EUS) can detect low-volume ascites (LVA) not apparent on computed tomography. The aim of this study was to assess the importance of LVA for management of patients with oesophagogastric (OG) cancer. Methods Patients with LVA were identified from a prospective OG cancer unit database between January 2002 and January 2006. Results Of 1118 patients staged with OG cancer, 802 had EUS. The incidence of LVA was 8·4 per cent overall but fell to 6·5 per cent when those with metastases on computed tomography were excluded. Only patients with gastric and OG junction carcinoma had LVA. Staging laparoscopy in the 21 patients with LVA revealed that 11 (52 per cent) were inoperable. The remainder had laparotomy and complete (R0) resection was possible in only five (50 per cent). In 106 patients who had staging laparoscopy after EUS without LVA, 37 (34·9 per cent) were inoperable and 56 of the remaining 69 (81 per cent) had R0 resection. Conclusion The presence of LVA on EUS is uncommon in patients with OG cancer but very important, being indicative of incurable disease in 76 per cent. This information will be helpful in counselling patients regarding management options and the low likelihood of potentially curative treatment.

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

In August 2004, the United Kingdom Department of Health advisory body published dyspepsia referral guidelines for primary care practitioners. These guidelines advised empiric treatment with antisecretory medications and referral for endoscopy only in the presence of alarm symptoms. The current study aimed to evaluate the effect of these guidelines on the detection of esophagogastric cancer.The study reviewed a prospectively compiled database of 4,018 subjects who underwent open access gastroscopy during the years 1990 to 1998. The main outcome measures for the study were cancer detection rates, International Union Against Cancer (UICC) stage, and survival.Gastroscopy identified esophagogastric carcinoma in 123 (3%) of the 4,018 subjects. Of these 123 patients, 104 (85%) with esophagogastric cancer had "alarm" symptoms (anemia, mass, dysphagia, weight loss, vomiting) and would have satisfied the referral criteria. The remaining 15% would not have been referred for initial endoscopic assessment because their symptoms were those of uncomplicated "benign" dyspepsia. The patients with "alarm" symptoms had a significantly more advanced tumor stage (metastatic disease in 47% vs 11%; p0.001), were less likely to undergo surgical resection (50% vs 95%; p0.001), and had a poorer survival (median, 11 vs 39 months; p = 0.01) than their counterparts without such symptoms.The use of alarm symptoms to select dyspeptics for endoscopy identifies patients with advanced and usually incurable esophagogastric cancer. Patients with early curable cancers often have only dyspeptic symptoms, and their diagnosis will be delayed until the symptoms of advanced cancer develop.