Historically, oesophageal and gastro-oesophageal junction adenocarcinomas were associated with a poor prognosis. The advent of neoadjuvant therapy has transformed the management of oesophageal and gastro-oesophageal junction adenocarcinomas further and offers the possibility to reverse disease progression, eliminate micrometastasis, and offer potentially better outcomes for these patients. This review provides an overview of landmark clinical trials in this area, with different treatment regimens considered over the years as well as potential therapeutic agents on the horizon that may transform the management of oesophageal and gastro-oesophageal junction adenocarcinomas further.

Abstract Background Upper GI (UGI) cancer patients face substantial physical and functional challenges which can compromise postoperative recovery. Prehabilitation, a proactive multidisciplinary intervention, offers a promising approach to optimize patient outcomes. This Delphi exercise aims to gather a consensus on the effectiveness of various prehabilitation strategies and interventions in improving functional capacity, reducing treatment-related complications, and enhancing quality of life among UGI cancer patients. Methods We performed a Delphi exercise in the form of an online survey emailed to a group of surgeons, anaesthetists, specialist nurses and allied healthcare professionals involved in the perioperative care of UGI cancer patients. A 2-staged iterative process was used to gather consensus on clinical practice and expert opinion. In the second round the survey was refined to evaluate specific strategies of prehabilitation more closely. Results In the first round, 14 statements were evaluated in addition to basic demographic data, information about the unit and clinician experience. 161 responses were collected from surgeons, anaesthetists, specialist nurses and allied healthcare professionals. Consensus was reached on formal assessment of patient fitness pre-operatively. However no consensus was achieved in the best method for doing so. In the second round we evaluated 22 statements after refining the questions to specifically target prehabilitation exercises and formal fitness assessments available for the perioperative care of UGI cancer patients. Conclusions Prehabilitation interventions hold significant potential in optimizing outcomes and improving the quality of life for UGI cancer patients undergoing major surgery. This Delphi exercise provides multidisciplinary expert consensus statements which can help guide clinicians in day-to-day practice as well as provide a basis for future guidelines and recommendations.

Active lupus nephritis (LN) in pregnancy is strongly associated with poor maternal and fetal outcomes and, therefore, has implications on the planning, timing, and management. Prepregnancy evaluation is essential for all LN patients with childbearing potential to ensure pregnancies proceed in a safe and timely manner. Both maternal and fetal risks are communicated to patient during the evaluation. Stratification into different risk profile groups is then made based on disease activity and organ impairment severity. Patients with LN are generally divided into 3 main groups. Patients with LN who become pregnant receive treatments that are nonteratogenic and optimal for fetal and maternal outcomes. Throughout the pregnancy period, these patients are monitored closely under surveillance by a multidisciplinary team of clinicians. The management of patients with LN in pregnancy can be challenging both diagnostically (distinguishing LN from pre-eclampsia and determining the role and timing of kidney biopsy) and therapeutically (LN flares during pregnancy and managing a newly diagnosed LN during pregnancy).

Background: Delayed gastric conduit emptying (DGCE) is a recognized complication of esophagectomy which can lead to prolonged vomiting, aspiration, and reduced oral intake postoperatively. To minimize the risk of DGCE, some advocate the use of pyloroplasty, however the practice is varied and controversial. The aim of this study is to investigate the effect of pyloroplasty on DGCE in esophagectomy patients. Methods: Consecutive patients that underwent an esophagectomy for esophageal cancer from September 2011 to December 2020 were identified from a prospectively maintained departmental cancer database at our institution. The primary outcome measured was the need for pyloric intervention following esophagectomy. Secondary outcomes included cardiac complications, pulmonary complications, anastomotic leaks, and chyle leaks. For those who had contrast swallow tests done prior to discharge from the index admission, dilated conduit and delayed gastric emptying were also investigated. Results: Of 458 patients included in the study, 77(17%) underwent pyloroplasty. Of the 381 patients who underwent esophagectomy without pyloroplasty, 44 (12%) of these patients later required at least one pyloric dilatation. None of the patients who underwent pyloroplasty later required pyloric dilatation. On multivariate analysis, younger age, respiratory complications after esophagectomy and pyloroplasty were significant predictors of the need for pyloric dilatation. Pyloroplasty was not significantly related to dilated conduit or delayed emptying on contrast swallow with P value of 0.979 and 0.147, respectively. Conclusions: Pyloroplasty reduces the need for pyloric dilatation postoperatively. However, further research is required to investigate the nature of this relationship, specifically in terms of contrast swallow.

Abstract Background Adenocarcinoma of the gastro-oesophageal junction (GOJ) remains a significant clinical problem that is increasing in incidence and is associated with a poor prognosis. The aim of this study is to determine the effects of the resection margins on survival and recurrence. Methods A retrospective study was conducted at our hospital from March 2001 till December 2022. All the patients that had oesophagectomy for gastro-oesophageal junctional (GOJ) adenocarcinoma were included in this study. Demography, staging, margins, type of neo-adjuvant chemotherapy and survival data were collected. Results Over the study, 174 patients had Gastro-oesophageal junctional adenocarcinoma. 42 of the patients had circumferential margins positive and 132 had negative circumferential margins. The median for survival is 18 months in circumferential margins positive and 31 months for the circumferential negative patients with a P value of <0.001 There were no patients with longitudinal margins positive enough to calculate any statical analysis The median of recurrence is 13.4 months for the circumferential margins positive and 26.8 months for the circumferential margins negative patients with a P value on 0.003 Conclusions The presence of any circumferential margin tumour will significantly affect the survival rate and recurrence rate.

Abstract Background Anastomotic leak is one of the major complications following oesophagectomy and is associated with a prolonged ICU and hospital stay with high mortality. Over the years, endoscopic vacuum therapy (EVT) has an evolving role in managing anastomotic leak. The aim of this study was evaluate our experience in the use of EVT in managing anastomotic leak. Methods A retrospective analysis was conducted in patients who underwent elective oesophagectomy at our tertiary centre from May 2021 to April 2022. Patient demographics, complication profiles, length of stay (LOS) and survival outcomes were collected. The details of endoscopic procedure, therapy results, and adverse events were evaluated. Endo-SPONGE® by B Braun Medical Ltd was used at our centre. Results Over the last 12 months, 3 out of 11 patients (27.3%) who had anastomotic leak were treated with EVT. All 3 patients were males and diagnosed with anastomotic leak on Day 8, 9, 9. Two patients were treated with a stent at the time of the diagnosis and the management changed to Endo-Sponge on the subsequent endoscopy as the defect increased in size. They required 3 and 8 times of sponge exchange respectively. One patient was managed with Endo-Sponge at the time of diagnosis and required 7 times of sponge exchange. The successful anastomotic leak healing rate was 100% and none of them required further endoscopic or surgical interventions. The median changing time interval of sponges was 3 days (range 2–5 days). The average sponge exchange rate was 6 times. The median duration of EVT was 25 days (range 18–29 days). No other adverse events occurred during EVT. The average LOS was 49.3 days. Conclusions EVT is an effective and safe treatment option in patients with anastomotic leak post oesophagectomy for oesophageal cancer. With careful patient selection, EVT can be considered as the first-line treatment instead of surgery. Future studies involving a greater number of patients are essential to evaluate the efficacy of EVT.

Background Chyle leak (CL) is an infrequent but potentially serious complication of oesophagectomy. Sarcopenia is an increasingly recognised prognostic factor in oesophageal cancer surgery. The aim of this study was to identify the influence of body composition measures on CL following oesophagectomy. Methods Patients who developed CL after oesophagectomy between January 2006–December 2020 were identified retrospectively from a prospectively maintained dataset. A control group of patients undergoing oesophagectomy, who did not experience chyle leak during the same time period, was also collected. Relationships between CL and demographics, operative factors and body composition measures were investigated as primary outcomes. Risk factors for severe CL were evaluated as a secondary outcome. Results There were 26 patients who developed a CL following an oesophagectomy. On univariate analysis, preoperative body mass index (BMI) (P=0.001), subcutaneous fat index (P=0.001) and total fat index (P=0.004) were significantly associated with CL. On multivariate analysis, a lower preoperative subcutaneous fat index was a significant independent predictor of CL (P=0.003). Sarcopenia, as an overall measure, was not found to be a significant predictor of developing CLs. No significant predictors of severe CL were identified. Conclusions A reduced preoperative BMI and body fat composition are risk factors for CL after oesophagectomy. Sarcopenia does not predict either the occurrence or severity of CL. This presents potentially modifiable risk factors for CL after oesophagectomy and emphasises the importance of physiological and nutritional optimisation before oesophagectomy.

Abstract Background Recently, peri-operative FLOT (fluorouracil plus leucovorin, oxaliplatin, and docetaxel) chemotherapy has superseded the ‘MAGIC’ regimen (epirubicin, cisplatin plus fluorouracil or capecitabine) as standard of care for locally advanced oesophago-gastric adenocarcinoma. However, concerns have been raised regarding the toxicity profile of FLOT. This study aims to compare the changes in body composition between both regimens. Methods 115 patients treated with FLOT (n = 61) or MAGIC (n = 54) who underwent an oesophagectomy for oesophageal or gastro-oesophageal junction (GOJ) adenocarcinoma between 2014 and 2020 at Queen Elizabeth Hospital, Birmingham, UK were analysed. Changes in body composition between pre- and post-neo-adjuvant chemotherapy were determined by analysis of computed tomography imaging. Results In both regimes, a large proportion of patients were sarcopenic prior to starting chemotherapy (FLOT 44.2%, MAGIC 44.4%; p=0.984). The percentage of patients who were sarcopenic increased post chemotherapy (FLOT 63.9%, MAGIC 57.4%; p=0.474). There was no significant pre vs post chemotherapy change in L3 skeletal muscle index in both regimes (FLOT 2.96 ± 4.03 vs MAGIC 2.76 ± 4.21; p=0.792). There was also no significant pre vs post chemotherapy change in L3 fat index in both regimes (FLOT 2.49 ± 22.6 vs MAGIC 5.78 ± 24.2; p = 0.453). Myosteatosis was observed in 44.3% of patients pre-FLOT and 42.6% of patients pre-MAGIC (p=0.857). This increased to 62.2% post-FLOT and 46.3% post-MAGIC (p=0.085). FLOT chemotherapy was associated with better tumour regression grade compared to MAGIC (p<0.001). Conclusions A large proportion of patients with locally advanced oesophageal/GOJ adenocarcinoma were sarcopenic and had myosteatosis prior to starting chemotherapy. A further loss of muscle and fat occurs during chemotherapy but there was no significant difference in loss of fat or muscle across both FLOT and MAGIC regimes. However, patients treated with the FLOT regime had better pathological response as compared with MAGIC.

Abstract Background Perforation of oesophagus and stomach during paraoesophageal hernia (POH) repair can be caused by traction on the lower oesophagus, gastro-oesophageal junction (GOJ) and fundus, or a thermal injury from the energy device during dissection. Iatrogenic complete transaction of oesophagus during elective laparoscopic POH repair is extremely rare. Here we reported this unusual complication. Methods A 79-year-old man with a history of hypertension and hypothyroidism underwent elective laparoscopic POH repair in a district hospital. During the surgery, oesophagus was transacted above the level of GOJ due to constant traction on the lower oesophagus and GOJ. Patient remained haemodynamically stable and was transferred to our tertiary centre next day. Patient was taken to theatre for midline laparotomy. Intraoperatively, stomach, omentum and transverse colon were in the chest and reduced carefully. The oesophageal stump, approximately 20cm from hiatus, was found in the mediastinum with the use of a nasogastric tube. It was also noted that there were several serosal tears on the proximal stomach and left gastric vessels were already divided. Unfortunately, oesophageal stump was ischaemic and friable. Therefore we decided to perform transhiatal oesophagectomy. Oesophagus was fully mobilised via cervical and abdominal incisions and was resected above the level of clavicle. Cervical oesophagogastric anastomosis was performed with semi-mechanical end-to-side EndoGIA 30mm blue and interrupted 3-0 PDS. Postoperatively, he was transferred to intensive care unit for ongoing care. Results Patient was off inotropes of Day 2 and extubated on Day 3 postoperatively. He developed pneumonia and atrial fibrillation and was treated with intravenous antibiotics and amiodarone. He has recovered well and is currently awaiting transfer to the ward. Conclusions Complete transection of oesophagus due to of traction in laparoscopic POH is an extremely uncommon complication. Transhiatal oesophagectomy can be considered as a management option in selected cases.

Background: Oesophagogastric cancer resection carries a morbidity, as high as 60%. Better patient selection, not only with regards to clinical stage but also fitness, reduces morbidity, and improves outcome. Assessment of body composition measures in particular sarcopenia and the incremental shuttle walk test (ISWT) are 2 such tools to evaluate patients’ fitness. We investigate the usefulness of these 2 tools in predicting post-operative outcomes following oesophagogastric resection. Methods: All patients who underwent oesophagogastric cancer resection between 2017 and 2019 and consented to participate in ISWT were included in the study. Patient demographics, comorbidity profile and distance walked in ISWT were collected from an electronic database kept locally. Body composition measures were calculated using pre-operative staging CT scans. Outcomes assessed included overall complications, major complications (Clavien-Dindo III-V) and overall survival. Results: Sixty-seven patients met the inclusion criteria. Seventy-nine percent of the cohort were males and the median age was 67. The majority had neoadjuvant chemotherapy (85%) and the overall complication rate was 69% with a major complication rate of 34%. There was no difference in complication rates between groups of patients who managed an ISWT distance of >350 m and ≤350 m. Multi-variate analyses showed that total fat index ( P = .041), myosteatosis (OR: 3.89; 95% CI: 1.04-16.76; P = .039) and sarcopenic obesity ( P = .028) were independent predictors of overall complications. The presence of sarcopenic obesity was associated with poorer overall survival ( P = .047). There was no correlation between skeletal muscle index and ISWT. Conclusion: ISWT does not predict post-operative morbidity following oesophagogastric cancer resection. However, sarcopenic obesity was associated with both higher overall complication rates and decreased overall survival. The assessment of body composition using CT scans is a useful pre-operative assessment tool for prediction of outcomes in patients undergoing oesophagogastric cancer resection

INTRODUCTION:Anastomotic leaks remain a major complication following oesophagectomy, accounting for high morbidity and mortality. Recently, gastric ischaemic conditioning (GIC) has been proposed to improve anastomotic integrity through neovascularisation of the gastric conduit. This systematic review and meta-analysis aim to determine the impact of GIC on postoperative outcomes following oesophagectomy. METHODS:A systematic literature search was performed to identify studies reporting GIC for any indication of oesophageal resection up to April 25, 2019. The primary outcome was anastomotic leak. Secondary outcomes were conduit necrosis, anastomotic strictures, overall and major complications or in-hospital mortality. Meta-analyses were conducted using random-effects modelling. RESULTS:Nineteen studies reported on GIC, of which 13 were comparative studies. GIC was performed through ligation in 13 studies and embolisation in six studies. GIC did not appear to reduce anastomotic leakages (OR 0.80, CI95: 0.51-1.24, p = 0.3), anastomotic strictures (OR 0.75, CI95: 0.35-1.60, p = 0.5), overall complications (OR 1.02, CI95: 0.48-2.16, p = 0.9), major complications (OR 1.06, CI95: 0.53-2.11, p = 0.9), or in-hospital mortality (OR 0.70, CI95: 0.32-1.53, p = 0.4). However, GIC was associated with reduced rates of conduit necrosis (OR 0.30, CI95: 0.11-0.77, p = 0.013). CONCLUSION:GIC does not appear to reduce overall rates of anastomotic leakage after oesophagectomy but seems to reduce severity of leakages. More in depth studies are recommended.

Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials. We describe the issues surrounding conduit necrosis affecting the stomach, jejunum and colon as an esophageal replacement and the advantages, disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.

BACKGROUND Malnourishment and sarcopenia are well documented phenomena in oesophageal cancer. Patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy have complex nutritional needs.AIM To examine the effect of regular nutritional support via feeding jejunostomy on overall body composition in patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy for oesophageal cancer.METHODS Retrospective data were collected for 15 patients before and after neo-adjuvant chemotherapy. All patients had feeding jejunostomies inserted at staging laparoscopy prior to neo-adjuvant chemotherapy and underwent regular jejunostomy feeding. Changes in body composition were determined by analysis of computed tomography imaging.RESULTS Patient age was 61.3 ± 12.8 years, and 73% of patients were male. The time between start of chemotherapy and surgery was 107 ± 21.6 d. There was no change in weight（74.5 ± 14.1 kg to 74.8 ± 13.1 kg） and body mass index（26.0 ± 3.8 kg/m~2 to 26.1 ± 3.4 kg/m~2）. Body composition analysis revealed a statistically significant decrease in lumbar skeletal muscle index despite regular feeding（45.8± 8.0 cm~2/m~2 to 43.5 ± 7.3 cm~2/m~2; P = 0.045）. The proportion of sarcopenic patients increased（33.3% to 60%）. Six patients（40%） experienced dose-limiting toxicity during chemotherapy.CONCLUSION Regular jejunostomy feeding during neo-adjuvant chemotherapy can maintainweight and adipose tissue. Feeding alone is not sufficient to maintain muscle mass. Further insight into the underlying processes causing reduced muscle mass in cancer patients may help to provide targeted interventions.

In the original publication of this article, most of the reference citations in Tables 1 and 2 were published incorrectly. The corrected tables are given in this correction.

To compare selected outcomes (30-day reoperation and total length of hospital stay) following emergency appendectomy between populations from New York State and England.

OBJECTIVE:The aim of this study was to compare mortality following emergency laparotomy between populations from New York State and England. SUMMARY OF BACKGROUND DATA:Mortality following emergency surgery is a key quality improvement metric in both the United States and UK. Comparison of the all-cause 30-day mortality following emergency laparotomy between populations from New York State and England might identify factors that could improve care. METHODS:Patient demographics, in-hospital, and 30-day outcomes data were extracted from Hospital Episode Statistics (HES) in England and the New York Statewide Planning and Research Cooperative System (SPARCS) administrative databases for all patients older than 18 years undergoing laparotomy for emergency open bowel surgery between April 2009 and March 2014. The primary outcome measure was all-cause mortality within 30 days of the index laparotomy. Mixed-effects logistic regression was performed to model independent demographic variables against mortality. A one-to-one propensity score matched dataset was created to compare the odd ratios of mortality between the 2 populations. RESULTS:Overall, 137,869 patient records, 85,286 (61.9%) from England and 52,583 (38.1%) from New York State, were extracted. Crude 30-day mortality for patients was significantly higher in the England compared with New York State [11,604 (13.6%) vs 3633 (6.9%) patients, P < 0.001]. Patients undergoing emergency laparotomy in England had significantly higher risk of mortality compared with those in New York State (odds ratio 2.35, confidence interval 2.24-2.46, P < 0.001). CONCLUSION:The risk of mortality at 30 days is higher following emergency laparotomy in England as compared with New York State despite similar patient groups.

BackgroundCachexia affects the majority with advanced cancer. Based on current demographic and clinical factors, it is not possible to predict who will develop cachexia or not. Such variation may, in part, be due to genotype. It has recently been proposed to extend the diagnostic criteria for cachexia to include a direct measure of low skeletal muscle index (LSMI) in addition to weight loss (WL). We aimed to explore our panel of candidate single nucleotide polymorphism (SNPs) for association with WL +/− computerized tomography‐defined LSMI. We also explored whether the transcription in muscle of identified genes was altered according to such cachexia phenotypeMethodsA retrospective cohort study design was used. Analysis explored associations of candidate SNPs with WL (n = 1276) and WL + LSMI (n = 943). Human muscle transcriptome (n = 134) was analysed using an Agilent platform.ResultsSingle nucleotide polymorphisms in the following genes showed association with WL alone: GCKR, LEPR, SELP, ACVR2B, TLR4, FOXO3, IGF1, CPN1, APOE, FOXO1, and GHRL. SNPs in LEPR, ACVR2B, TNF, and ACE were associated with concurrent WL + LSMI. There was concordance between muscle‐specific expression for ACVR2B, FOXO1 and 3, LEPR, GCKR, and TLR4 genes and LSMI and/or WL (P < 0.05).ConclusionsThe rs1799964 in the TNF gene and rs4291 in the ACE gene are new associations when the definition of cachexia is based on a combination of WL and LSMI. These findings focus attention on pro‐inflammatory cytokines and the renin–angiotensin system as biomarkers/mediators of muscle wasting in cachexia.