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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.

Medicalization refers to the process by which ordinary human problems and experiences—such as depression, anxiety, addiction, and child hyperactivity—come to be defined and treated as distinct medi...

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.

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

Background 15% of the adult population are estimated to have gallstones (GS) and managing GS related disease can represent a significant challenge to surgical and endoscopic services alike. One particular challenge is the management of bile duct calculi (BDC), and treatment can vary according to the unit/institution. NICE has published guidelines (CG188) on the management of GS disease with the recommendation that bile duct clearance and cholecystectomy be offered for symptomatic and asymptomatic BDC. This retrospective audit was performed to determine compliance of a single centre with respect to offering cholecystectomy following ERCP for BDC. Methods A retrospective audit was performed for the year 2018 at a single centre utilising the trust ERCP database. The audit was analysed against NICE guideline CG188 and specifically whether patients treated with ERCP for BDC were then treated with cholecystectomy or had a documented justification as to why cholecystectomy was declined. 2018 was chosen so that at least a 2-year period of follow-up could be analysed. As well as the trust ERCP database, the trust electronic documentation record and paper notes were consulted to determine compliance with the guideline. Results 149 ERCPs were performed on 121 patients at this centre in 2018. Of these, 82 patients were included as 39 had an ERCP for malignant disease or had already had a cholecystectomy. Of those 82, 51 (62%) had an ERCP as an emergency while 31 (38%) had an elective procedure. The median age was 65, 54% being male and 46% female. 45 (55%) had a cholecystectomy following ERCP, 29 as an emergency, and 16 electively. Of those 37 who did not have a cholecystectomy, 20 (54%) had no recorded documentation to justify a decision not to proceed to cholecystectomy. Conclusions GS disease has the potential to cause significant morbidity. If an ERCP has been performed for BDC, NICE recommends that cholecystectomy should be offered to mitigate further GS related complications. Patients may of course decline an operation, or a joint decision made not to pursue operative management due to identified surgical risks. This audit demonstrated that 54% of patients at this institution who did not have a cholecystectomy following ERCP had no documented reason why cholecystectomy was declined. Robust follow-up and documentation measures have since been put in place and a follow-up audit is being performed to monitor improvement.

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

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

The Greenland ice sheet surface melt has increased substantially in intensity and spatial extent over the recent decades. The rapid migration of melt towards upstream areas of Greenland ice sheet is expected to incur major changes in hydrological behaviour of the ice sheet and outlet glaciers along with changes in export fluxes of carbon, methane, and other nutrient fluxes, which, in turn, will further affect the downstream ecosystem of rivers, fjords and oceans. Subglacial environments are emerging as ecological hotspots, urging detailed understanding of interaction between subglacial hydrology and biogeochemistry. However, due to their inaccessibility, the hydrology and geochemistry of subglacial environment thus far lacks a detailed understanding. As such this area is now the focus of many major projects in Greenland and Antarctica. Under the NuttI (Nutrient factories under the Ice) project, we aim to develop a hydrological-biogeochemical model framework to investigate seasonal and inter-annual evolution of subglacial hydrology system and quantify carbon and nutrient export from subglacial environments to proglacial rivers. We use the subglacial hydrology model GlaDS (Glacier Drainage System model) to simulate seasonal and interannual evolution of distributed and channelized subglacial water flow while calculating subglacial water storage, residence time, water flux and effective pressure. A subglacial erosion scheme is coupled to the model to calculate physical weathering occurring especially in early melt and peak melt season due to glacier sliding and higher water flow, respectively. All these parameters are used in a geochemical model to quantify subglacial chemical weathering fluxes. The meltwater becomes chemically enriched subglacially and reaches the glacier outlet through subglacial channels. We also intend to further develop the model to investigate processes such as subglacial cycling of silica and production of methane. We primarily use the coupled model to simulate Leverett glacier, a land-terminating outlet glacier in southwest Greenland which has been well studied with different geophysical measurements and long-term monitoring. The model output is validated with the in-situ measurement of discharge and export fluxes in the proglacial river of the land-terminating glacier.

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 case study presents a project based on a spatial redesign at Auckland City Hospital. The project aimed to improve the public waiting area located outside an intensive care unit – a space where...

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.

Open Dialogue (OD) is a recently developed approach to supporting individuals with psychosis, which focuses on a mental health team working together, and collaboratively with the person affected by psychosis. This chapter provides an introduction to the OD approach to psychosis and what it entails. The chapter begins with Nick’s personal account of experiencing the OD approach following his difficulties with psychosis. Key features highlighted in this account include the openness and empathic acceptance of difficult experiences encouraged by the approach, and the opportunities provided for reflection on these experiences. Challenges of the approach are also noted. In the second part of this chapter Niklas, an OD therapist, gives an account of the principles and ideas behind OD. A case example is given to help illustrate how OD works in practice. The research evidence supporting OD and the principles it is based on are discussed.

The accelerated decline in British manufacturing is palpable. One of the industries significantly affected by this was lace. Nottingham, and its surrounding district, used to be the mainstay of Bri...

Drawing on hospital reports, committee minutes and the local press, this article examines the changing landscape of urban civic culture and challenges the pessimistic accounts of charitable financial support for voluntary hospitals in inter-war England. Through case studies of hospitals in four of the largest cities in the country, it assesses the extent to which voluntary resources of time and money continued to underpin day-to-day institutional income, stimulate the development of the hospitals' estates and investments, and enable hospitals to cut costs through the receipt of gifts in kind. It argues that by broadening the bases of charitable income, hospitals were freed from their dependence on the wealthy thus ensuring their transformation to modern community resources for all.

With few dissenting voices, the historiography of twentieth-century urban civil society has been relayed through a prism of continuing and escalating elite disengagement. Within a paradigm of declinism, academics, politicians and social commentators contrast a past offering a richness of social commitment against a present characterized by lowering standards in urban governance. Put simply, the right sorts of people were no longer volunteering. Yet the data for such claims is insubstantial, and the applied methodology flawed. What are lacking are detailed empirical studies which offer flexible measures of status across a range of voluntary and political activities, so that we can better understand the social trends of urban volunteering across the first 50 years of the twentieth century.

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).

This is a welcome addition to our understanding of the British home front experience during the Second World War. It might be thought that there was little new left to say. There exists, after all,...

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.

The impact of ‘human relations’ ideology remains contentious. This article examines how such ideas were deconstructed in the British building industry during the postwar battle to raise productivity. Construction offers a useful testing bed for a strategy based on organic, workplace co-operation: it has the dichotomous attributes of past ‘human neglect’ within a reputed industrial relations framework of harmonious mutuality. The industry suffered heavily from unemployment before 1939. It might be expected, therefore, that mindsets changed significantly with the onset of full employment. But did a common understanding of ‘human relations’ exist to disable workplace antagonisms and past insecurity? Indeed were such constructs viewed as a priority, and in that sense have meaning? This article concludes that the past continued to haunt the industry, and that meanings were ambiguous and misconstrued, but that nevertheless a new purposeful, common agenda arose.

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.