Background: Minimally invasive esophagectomy (MIE) and hybrid esophagectomy (HE) are both established techniques for esophageal cancer resection. Despite MIE's potential to reduce morbidity, its superiority over HE is not conclusive. This study evaluates patient outcomes following MIE and HE at a medium-volume tertiary center in the United Kingdom (UK) over a 10-year period. Methods: A retrospective analysis of prospectively maintained database included patients undergoing Ivor-Lewis two-stage MIE or HE for esophageal cancer between January 2013 and December 2023 with at least 1-year follow-up. Primary outcomes were 3- and 5-year survival. Secondary outcomes included postoperative complications, anastomotic leak rates, and 30/90-day mortality. Results: Of 456 patients, 271 underwent MIE and 185 underwent HE. Median ages were 68 (MIE) and 71 (HE) years (P<0.001). Adenocarcinoma was the predominant histology [84.1% (MIE), 94.1% (HE)]. MIE had longer operating times (613 vs. 470 minutes, P<0.001), but shorter hospital stay (7.0 vs. 8.55 days, P=0.004). Pulmonary complications occurred in 29.1% (MIE) and 35.6% (HE) (P=0.14). Anastomotic leak rates were comparable [15.5% (MIE), 16.8% (HE), P=0.72]. Clavien-Dindo III + complications were similar [22.1% (MIE), 24.3% (HE), P=0.59]. MIE yielded higher lymph node retrieval (38 vs. 27, P<0.001). R0 resection rates were 73.1% (MIE) and 78.4% (HE) (P=0.20). Three-year survival was 61.3% (MIE) and 58.9% (HE) (P=0.62); 5-year survival was 52.0% (MIE) and 49.2% (HE) (P=0.55). Conclusions: MIE and HE demonstrate comparable survival and complication profiles. MIE's shorter hospital stay and higher lymph node yields affirm its efficacy. Further prospective studies with quality-of-life outcomes are warranted to refine surgical strategies.

BACKGROUND:HbA1c, a measure of long-term glycaemic control, has been identified as a potential prognostic risk factor for pancreatitis severity, yet there is a paucity of evidence on its association with pancreatitis outcomes in people with and without diabetes. We, therefore, conducted a systematic review and meta-analysis to assess the current body of evidence. METHODS:Articles from January 1980 to March 2025 were screened using PubMed and the Excerpta Medica database (Embase). Randomised control trials (RCTs), cohort, and case-control studies were permitted for inclusion if they used an appropriate method for both acute pancreatitis (AP) diagnosis and severity classification. Quality assessment was performed using the Newcastle-Ottawa scale (NOS), and random effects models reporting pooled odds ratios (ORs) were estimated in our meta-analyses. RESULTS:Our search generated 2,270 results, from which two studies were eligible for inclusion with a total of 1,195 participants. Both studies were deemed to be at low risk of bias. The results of our meta-analyses demonstrated an increased odds of developing severe AP with increased HbA1c levels (OR = 2.14, 95% confidence interval (CI) 1.32-3.48). Elevated HbA1c levels were also found to increase the odds for developing local pancreatic complications (OR = 1.71, 95% CI 1.25-2.34) and systemic complications (pooled OR = 2.82, 95% CI 0.49-16.28). CONCLUSIONS:Our review suggests that elevated HbA1c levels may increase the likelihood of developing severe AP as well as local and systemic complications. The results of the review are limited due to the small number of included studies. We recommend that large multicentre cohort studies be conducted to further investigate this relationship.

Symptomatic failure of anti-reflux surgery may reflect functional gastrointestinal (GI) disorders rather than surgical failure. A regional specialist benign Oesophago-Gastric (OG) multidisciplinary team (MDT) provides expert evaluation of benign OG disorders. This study aimed to assess the MDT’s role in identifying functional diagnoses and guiding appropriate management in patients with ongoing symptoms after anti-reflux surgery. A retrospective review was undertaken of all cases discussed in the regional specialist benign OG MDT at a UK tertiary referral centre between January 2023 and May 2025. Patients with ongoing or recurrent symptoms following fundoplication were identified for inclusion. All patients underwent gastroscopy, oesophageal physiology testing and barium swallow prior to discussion. The primary outcome was the proportion of patients diagnosed with a functional GI disorder. Of 105 total cases discussed, 16 patients (15%) presented with ongoing or recurrent symptoms following fundoplication, most commonly laparoscopic Nissen fundoplication (90%). The cohort was 90% female, with a median age of 54 years (range 25–77). Median time to MDT discussion was 19 months post-operatively. Specialist review identified supra-gastric belching in one patient who was referred for cognitive behavioural therapy. Three patients were diagnosed with reflux hypersensitivity and started on selective serotonin reuptake inhibitors. One in four patients being considered for revisional surgery had a functional GI disorder. Specialist MDT review facilitated diagnosis and appropriate non-surgical management. The specialist benign OG MDT identified a significant proportion of patients in whom revisional surgery would have been contraindicated. An MDT approach to complex anti-reflux surgery should be nationally mandated.

Postoperative myocardial infarction (MI) is a recognized complication of oesophagectomy, associated with significant perioperative morbidity and mortality. Despite advances in surgical and perioperative management, contemporary data on its incidence and associated risk factors remain limited. To determine the incidence of postoperative MI following oesophagectomy at Norfolk and Norwich University Hospital (NNUH), and to identify associated demographic and perioperative risk factors. A retrospective analysis was conducted using a prospectively maintained database of 526 consecutive patients who underwent either minimally invasive oesophagectomy (MIO, n=273) or laparoscopic-assisted oesophagectomy (n=253) between January 2013 and December 2023. Postoperative MI was defined as a new diagnosis within 30 days of surgery, confirmed by clinical, biochemical, or radiological criteria. Demographic, operative, and postoperative variables were analysed descriptively. The overall incidence of postoperative myocardial infarction (MI) was 4.2% (22 out of 526 patients). Subgroup analysis showed a notably higher incidence following minimally invasive oesophagectomy (MIO) at 7.3% (20/273), compared to 0.8% (2/253) in those who underwent laparoscopic-assisted oesophagectomy. Among the 22 patients who developed postoperative MI, risk factor analysis revealed that 90.9% (20/22) had a prior history of MI and were male, 81.8% (18/22) had an operative duration exceeding 600 minutes, 22.7% (5/22) were older than 75 years, 13.6% (3/22) experienced an anastomotic leak, and 4.5% (1/22) developed postoperative pneumonia. These findings are consistent with international data reporting MI incidence rates between 4% and 12%, underscoring the influence of both patient-specific and procedural factors. Postoperative MI occurred in 4.2% of oesophagectomy patients at NNUH, predominantly among those undergoing MIO. Prior cardiac history, male sex, and prolonged operative duration were key risk factors. Accurate differentiation between pre-existing and new-onset MI remains essential for risk stratification. Optimization of perioperative cardiac risk management protocols is recommended.

The recommendation is to deliver adjuvant therapy within 3 months of oesophago-gastric cancer resection. The timing of adjuvant therapy commencing was assessed between two study periods. Demographic and timing data was collated for elective oesophago-gastric cancer resections (excluding GISTs) between February 2023-February 2024 for round 1 and March 2024 - March 2025 for round 2. The interventions included collaboration with the relevant specialities on improving the administrative and logistical challenges in the pathway to adjuvant therapy. There were 55 cases in round 1 and 38 cases in round 2 with a median age of 69 (43-86) and 68 (43-84) respectively. The median (IQR) length of stay was 9.00 (16) days and 8.50 (11) days in round 2. 58% of patients in round 1 commenced adjuvant therapy; this was 71% in round 2. The median (IQR) time between surgery and the commencing adjuvant therapy was 85.00 (40.25) days in round 1 and 82.00 (23.00) days in round 2. 59% of suitable patients commenced adjuvant therapy within 3 months of surgery in round 1 and this was 70% in round 2. There were no statistically significant differences in median time or percentage of adjuvant therapy within 3 months between the two rounds. In round 1, the main barriers to adjuvant therapy commencing promptly were slow postoperative recovery (30.8%). In round 2, delays in receiving an oncology appointment contributed the most (37.5%). Barriers to the timely commencement of adjuvant therapy include surgical complications, nutritional deficiencies, and logistical challenges.

Curative management for oesophagogastric adenocarcinoma traditionally involves four cycles of neo-adjuvant chemotherapy, FLOT (fluorouracil, leucovorin, oxaliplatin and docetaxel) followed by surgery and four cycles of adjuvant FLOT. Chemotherapy aims to reduce tumour bulk and prevent recurrence. Chemotherapy agents, especially fluorouracil, are known to cause cardiotoxicity which subsequently can impact cardiac function. We discuss three cases of cardiac dysfunction during neoadjuvant chemotherapy for patients diagnosed with oesophagogastric cancer. The first patient (56M) presented with chest pain following their first cycle of FLOT for oesophageal cancer, presumed squamous cell carcinoma. Echocardiogram showed severely impaired left ventricular (LV) function (ejection fraction of 35%). Chemotherapy was stopped. He was listed for surgery after a cardiac MRI showed a full recovery in his LV function however the tumour was too advanced and not resectable. The second patient (64F) had completed her neoadjuvant FLOT for oesophageal adenocarcinoma. Pre-operative echocardiogram showed a mildly dilated left ventricle with severe systolic dysfunction (estimated ejection fraction 25-30%) and deemed not fit for surgery. She received palliative radiotherapy during which her LV function improved and went on to have an oesophagectomy. The third patient (65M), diagnosed with a gastric adenocarcinoma, suffered an NSTEMI following their third-cycle of FLOT. A cardiac MRI revealed hypertrophic cardiomyopathy. He underwent a gastrectomy although did not have any adjuvant chemotherapy due to the cardiac risk. He subsequently had a recurrence within one-year of surgery. Our cases demonstrate the importance of cardiac monitoring during chemotherapy for these patients and highlights the significant impact when chemotherapy is disrupted.

Abstract Background Eosinophilic Esophagitis (EoE) is growing in incidence internationally. It is an immune-mediated disease that is characterised by esophageal mucosal eosinophilia and esophageal dysfunction. Awareness of EoE is also crucial for Esophagogastric surgeons as symptoms may mimic reflux disease or neoplasia, key considerations for an accurate differential diagnosis. Presently, there are no incidence estimates of EoE in the adult population in the UK. This study seeks to establish a cohort of EoE patients in Norfolk, a county in the East of England region, and to describe the incidence, characteristics, and diagnostic features of affected patients in both the adult and paediatric populations. Methods A retrospective analysis was performed of a prospectively maintained pathology database servicing a population of 761,000 persons in Norfolk. All newly diagnosed cases of EoE across a seven-year period between January 2017 and December 2023 were identified. Patients included for analysis had a histological diagnosis of EoE with >15 eosinophils/hpf and symptoms of oesophageal dysfunction. Patient electronic health care records were reviewed for histology reports, endoscopic findings, and clinical history. The primary outcome was incidence of EoE within the county. Secondary outcomes assessed included: patient characteristics; allergy and atopy history; endoscopic features, biopsy protocol and referral indication. Results 187 (median age 43 (4-85) years, Male: Female (126:61)) new cases of EoE were identified, of whom eight were in the paediatric age group of ≤16 years. The average annual incidence of EoE was 4.29 [95% CI 2.92, 5.66] and 0.89 [95% CI 0, 1.39] per 100,000 person/years in adult and paediatric groups respectively, with a significantly higher incidence in adults (RR 4.86 (95% CI [2.39 – 9.85] P<0.005) (Figure 1). The most common referral indications for endoscopy were dysphagia (80.7%) and food bolus obstruction episodes (25.1%). The most common endoscopic feature of EoE was circular rings (49.2%). Conclusion This is the first study reporting incidence of EoE in the UK adult population. There was a significantly greater incidence of EoE in adults compared to the paediatric population. However, there was no significant change in incidence of EoE in either group over the study period. Incidence estimates identified are similar to those reported in other European populations. Importantly 18.2% of patients had normal appearance of oesophagus on endoscopy, which reinforces the need to take oesophageal biopsies where there is clinical suspicion. Ideally, prospective registry data is needed for a comprehensive characterisation of incidence and prevalence of EoE.

Abstract Background Oesophagogastric (OG) emergency conditions may require specialised intervention in centralised OG cancer surgery units. Recently published AUGIS OG commissioning guidance recommends OG units provide 24/7 on-call cover for internal and external OG emergency referrals with a formalised rota. However, there may be widespread inconsistent provision of OG emergency services across United Kingdom (UK) regions with significant workforce, capacity, and funding challenges. This may lead to barriers to provision of on-call OG services. Currently there is no research that establishes current OG on-call coverage or explores OG surgeons’ perceptions and attitudes towards providing this service. Method An 11-item electronic questionnaire was developed at an OG cancer unit to identify OG consultant emergency on-call coverage at NHS OG cancer units in the UK. The questionnaire was initially piloted among OG surgeons for refinement and subsequently disseminated through professional networks (AUGIS), direct contact, and snowballing. It was active for three weeks in January 2024. Secondary outcomes included: identifying barriers to providing an emergency OG service; defining the scope of conditions acceptable for transfer; understanding current referral mechanisms and examining OG consultant attitudes and perceptions towards providing an on-call OG service. Results 71 consultant OG surgeons from 26 UK OG cancer units responded (Figure 1). 61% (n=43) report participating in a 24/7 formalised emergency OG on-call rota, staffed by a median of 5 (range 3-8) surgeons. Among the nine respondents from three centres without a formal OG emergency service, all cited limited funding as the primary barrier. Only 31% (n=19) used auditable referral mechanisms like email or online systems. 97% percent (n=69) of respondents perceive an OG emergency service to be beneficial for patients, and 86% (n=61) agreed it should be nationally mandated for OG cancer units to provide a 24/7 service. Conclusion Consultant OG surgeons recognize the importance of delivering high-quality OG emergency services. However, the data indicates inconsistent delivery across the UK. Given the seriousness of OG emergencies, mandatory provision of this service with appropriate funding and remuneration is essential. Several workforce challenges, including potential impacts on OG cancer resection volume and provision of General Surgical on-call, need to be addressed. Ultimately, patients require timely and specialised intervention. As one respondent emphasized: "A situation where surgeons in non-OG centres can spend a whole night ringing around various OG centres looking for help with a Boerhaave perforation is unacceptable."

Background: Endoluminal vacuum therapy (EVT) for the management of anastomotic leak (AL) following esophagectomy conventionally uses a sponge applied to vacuum suction. This typically requires exchanges under a general anaesthesia (GA) every 3-5 days and may use self-made adaptations or commercially available devices. We report our experience of a novel EVT system using an endoscopically placed fenestrated surgical drain with applied vacuum suction. We aimed to see whether this was effective, safe, and reduced the frequency of endoscopic exchanges under GA. Methods: A retrospective study was conducted between August 2019 and March 2023 at a tertiary hospital in the United Kingdom. Patients included had undergone esophagectomy for Esophageal cancer and had developed AL following the procedure which was managed primarily using EVT with drain. The primary outcomes assessed were complete healing of the AL and 90-day mortality. Results: Twenty patients met inclusion criteria. Eighteen out of 20 patients (90%) achieved full healing of the AL, with two patients declining further EVT due to discomfort. There were no serious adverse events associated with EVT and no patients underwent reoperation for anastomotic revision. The 90-day mortality was 0% and the median duration of EVT was 19.5 days (range, 5-72 days). The median duration between drain repositioning was 7 days (range, 2-19 days), 56% of which were performed without GA. Conclusions: EVT with drain may be a safe and effective technique for management of AL after esophagectomy. EVT with drain can be performed without GA and permits a longer interval duration between endoscopic device repositioning procedures than similar approaches where an endosponge device is utilised. The benefits of this approach compared to alternative AL management strategies are numerous including reducing the need for frequent endoscopic device exchanges under GA and reduced material cost given the same drain can be used for the duration of therapy.

Abstract Background Assessing frailty in elderly patients is pivotal for preoperative risk stratification. Whilst the modified Frailty-Index (m-FI) and Clinical Frailty Scale (CFS) have been used to predict postoperative mortality and morbidity in various surgical contexts, their prognostic value for complications and overall survival following esophagectomy remains uncertain. Several studies have assessed pre-operative application of frailty indices and whether they have prognostic value for long-term postoperative outcomes, however, none have compared m-FI and CFS in patients undergoing esophagectomy. This study examines and compares m-FI and CFS with overall survival and post-operative complications in patients undergoing Minimally Invasive Esophagectomy (MIO). Methods We retrospectively analysed data from a prospectively maintained database, including patients aged ≥65 years undergoing MIO for esophageal cancer from January 2014 to December 2023, at a high-volume esophago-gastric tertiary centre. We compared the m-FI 11 and m-FI 5, CFS, all measuring frailty parameters in surgical patients. Frailty was defined as m-FI 11 ≥3, m-FI 5 ≥2, or CFS ≥4, based on the current literature evidence for application of these frailty assessment tools. Primary outcomes were 2- and 5-year all-cause mortality, with anastomotic leak, serious complications (Clavien-Dindo grade ≥IIIa) and average length of stay (LOS) as secondary outcomes. Results Among 174 patients (median age 72 years, range 65-85, male-to-female ratio 4:1), no significant associations were found between age, sex, TNM stage, and pre/post-op chemoradiotherapy within each scoring category. Neither tool showed significant associations for 2-, 5-year, and overall mortality (Table 1), nor for average length of stay. However, an m-FI 5 score ≥2 exhibited an odds ratio (OR) of 2.41 (95% CI 1.00–5.78, p = 0.049) for anastomotic leak, and a CFS score ≥4 had an OR of 2.46 (95% CI 1.02–5.90, p = 0.044) for serious complications. Conclusion In frail patients undergoing MIO, both the m-FI and CFS tools demonstrated no significant prognostic value for predicting overall survival. However, m-FI 5 ≥2 correlated significantly with anastomotic leaks, while CFS ≥4 correlated with serious complications. Relying on scoring tools for frailty assessment may inadvertently trivialise what is intended to be a multidimensional evaluation of health domains. Nevertheless, their utility in predicting complications should not be overlooked. We propose a more strategic use of frailty assessment tools to triage patients for comprehensive geriatric evaluation. This approach identifies patients at highest risk of complications and facilitates targeted prehabilitation for optimising outcomes.

Abstract Background Decision making in benign OG pathology can be particularly challenging given the overlap with functional disorders, such as reflux hypersensitivity. A specialist benign oesophagogastric (OG) multidisciplinary team (MDT) may improve our ability to triage potential surgical candidates from those with functional conditions. Unlike in OG cancer, there is a paucity of evidence to support an MDT based approach in benign OG surgery. This study aims to report our experience of introducing a specialist benign OG MDT in an OG tertiary centre in the UK, examining the effect on decision making and an assessment of its acceptability and utility to clinicians. Method A review of consecutive cases discussed in the specialist benign OG MDT since inception in 2022 was undertaken. We reviewed indications, treatment plans and outcomes, any alteration in treatment pathway and final decisions. The primary outcome was the proportion of patients with a change in management as a result of MDT discussion. Where applicable, results were reported using descriptive statistics. A seven-item electronic questionnaire was also circulated to MDT members (OG surgeons, specialist gastroenterologists, GI radiographers, GI physiologists, and doctors in training), to assess the acceptability and perceived utility of the meetings. Results 74 patient cases were discussed (median age 57.5 (25-79) years). 71/74 (96.0%) of referrals were made by OG surgeons, most commonly to discuss anti-reflux procedures (53/74 (71.6%)). 34/74 (45.9%) patients had undergone previous surgery, most commonly laparoscopic fundoplication. MDT discussion led to a change in management in 43/74 (58.1%) case with recommendations of further investigation (23.0%), further OG clinic review (18.9%) and 21.6% listed for surgery. 12/74 (16.2%) were referred to other specialist services, including clinical psychology. Survey confirmed that all MDT members found their understanding of oesophageal physiology and subsequent decision-making ability in clinic was greatly enhanced. Conclusion Our results show that the complex benign MDT is an effective tool, demonstrating changes to management in over half of cases discussed, including recommending surgery less frequently following specialist review of physiology investigations. Such tests effectively identify functional disorders, such as rumination, highlighting a need for clear onward referral pathways involving specialist psychologists. The meetings have also proven to be valuable learning tools for all attendees of all grades. We strongly believe that adopting an MDT approach to benign OG conditions will enhance collaborative decision making, improve patient outcomes and therefore should be nationally mandated and recommended through AUGIS guidelines.

Introduction: The last UK-wide audit of the management of acute upper gastrointestinal bleeding (AUGIB) was conducted in 2007. Re-evaluation of current practice is needed, because since then, there have been several initiatives to improve the management of AUGIB including new guidelines, innovative endoscopic therapy, service delivery improvements and expansion of endoscopy provision. Methods and analysis: Consecutive, unselected presentations with AUGIB across all UK NHS hospitals were prospectively enrolled over a 2-month period between May and July 2022. Data will be collected on patient characteristics, comorbidities, use of anticoagulant drugs, transfusion, timing and type of diagnostic and therapeutic procedure, length of stay and mortality. Clinical practice will be audited against predefined minimum standards of care for AUGIB and compared to the results of the 2007 UK-wide audit. Data will be collected on the availability and organisation of care as well as the provision of training for specialist registrars in endoscopic management of AUGIB.Ethics and dissemination: This audit will be conducted as part of the National Comparative Audit of Blood Transfusion through collaboration with specialists in gastroenterology, haematology, surgery, and interventional radiology. Individual site reports will be provided alongside a UK-wide report disseminated through specialist societies and publications in peer-reviewed journals. The study has been funded by National Health Services Blood and Transplant and the British Society of Gastroenterology and endorsed by the Royal Colleges of Physicians, the British Association for the Study of the Liver, the Association of Upper GI Surgeons, and the British Society of Interventional Radiology.

Abstract Background Evaluating frailty in the elderly population is crucial in preoperative assessment to identify high-risk patients. The modified frailty index (m-FI) is known to predict postoperative mortality in various surgical populations, but its predictive value in oesophagectomy patients' long-term mortality is unclear. No studies have specifically quantified frailty and its association with long-term postoperative mortality in oesophagectomy patients. This study investigates the association between m-FI score and long-term mortality in patients undergoing minimally invasive oesophagectomy (MIO). Methods The m-FI is a scoring tool of 11 parameters quantifies frailty in surgical patients. Retrospective analysis (1/1/2014-31/12/2023) of patients aged ≥75 years undergoing minimally invasive oesophagectomy procedures for cancer, at a single h[ka1] igh volume tertiary referral centre was carried out. Primary outcome was defined as 1-year all-cause mortality with overall length of survival as the secondary outcome. After sensitivity analyses m-fi score of less than 1 or greater than 2 were most predictive of mortality. Results Ninety-one patients (mean age 78 years, age range 75-88, male to female ratio of 4:1) were included, with a median m-FI score of 1 (range: 0-5). Patients with an m-FI score of ≥2 had a higher 1-year mortality rate (30% vs. 19%, p=0.195) and shorter overall median survival time (34 months vs. 47 months, p=0.399) compared to those with a score of ≤1. After adjusting for covariates, including preoperative chemotherapy, age, sex, and cancer staging, an m-FI score of ≥2 had a hazard ratio of 1.65 (95% CI: 0.68 to 3.98, p=0.267) for 1-year mortality compared to ≤1. Conclusions The m-FI tool can predict post operative mortality in a range of surgical specialities. The results of our study would suggest that higher m-FI score would correlate with worse long term mortality outcomes, however at this stage the m-FI tool cannot be applied in a clinical setting to accurately define elderly patient's probable outcome following MIO. Additional multicentre data is needed to establish its true predictive value in this patient cohort.

Link to Video: https://www.dropbox.com/s/wpr3s097g50oadl/Colonic%20interposition%20%28ISDE%20SUBMISSION%29.mp4?dl=0. Description of Video: We report our learnings from a complex surgical case of Ivor Lewis esophagectomy with colonic conduit in a patient who had undergone multiple previous abdominal and thoracic operations. This seventy-two-year-old man was found to have an esophageal adenocarcinoma (T4N0M0) in the distal esophagus with a significant surgical background: Whipple’s procedure for pancreatic cancer; Left lower lobectomy for lung cancer; Right pneumonectomy for recurrent pneumothoraces and a defunctioning stoma for chemotherapy associated anal fistula. To our knowledge, no such case of colonic interposition for esophagectomy has been reported in the literature for a patient with such extensive surgical history. This presented significant surgical and anaesthetic challenges which are explored in the video. Principally the need for extensive planning to anticipate risk and modify procedural steps to account for these accordingly. For example, the operation began with a right thoracotomy, given the possibility that dense adhesions from previous surgery could obstruct safe dissection and subsequently the procedure could be aborted before any critical steps were made. Additionally, we consider the importance of involving other surgical specialities to aid with safe dissection and delineation of anatomy. Each of the key operative steps are described and paired with real-time video footage. Post-operatively we describe how the risk of anastomotic leak given a high-risk anastomosis may be reduced through pre-emptive Endoluminal Vacuum therapy. We also discuss the importance of recognising and managing feculent aspiration pneumonia which is common following this surgery. Discussion of this case and our operative approach would serve to highlight how surgery remains a feasible option for patients despite complex anatomy and surgical history; provided risks are anticipated and appropriately managed.

Abstract Background Anastomotic leak (AL) is a life-threatening complication following esophagectomy. Early and accurate diagnosis is key. Although computerized tomography (CT) scan is a widely employed diagnostic modality, there is no consensus on whether oral contrast should be used in addition to IV contrast. We sought to survey protocols regarding the use of oral contrast amongst specialist radiologists when using CT scan to diagnose AL. Methods An online questionnaire was sent to 27 consultant gastrointestinal (GI) radiologists with a subspecialist esophageal interest from 11 tertiary centres. Participants were primarily asked for their preferred imaging modality to diagnose AL, choice of contrast if a CT scan was used (assuming no contraindications for IV contrast) and an explanation for their preferred choice of investigation. Results The response rate was 96.3% (n = 26). Most participants (16 [61.5%]) used CT scan as first choice modality, while six (23.1%) used fluoroscopy and two (15.3%) used CT scan and fluoroscopy. With CT scan, half the participants preferred using both oral and IV contrast to IV contrast alone. No participants chose oral contrast alone. Some participants who used oral contrast felt it helped differentiate between normal post-surgical changes and true leaks. Limitations of using oral contrast included concerns of missed leaks involving the anterior aspect of the esophagus and lowered enhancement of the esophageal mucosa. Conclusion The majority of radiologists favor using oral contrast in addition to IV contrast for CT scan for suspected AL. In spite of this, practice is variable even amongst radiologists from the same unit. The lack of consensus emphasizes the need for further research to establish best practice and formulation of guidelines.

Background:The oesophageal microbiome is thought to contribute to the pathogenesis of oesophageal cancer. However, investigations using culture and molecular barcodes have provided only a low-resolution view of this important microbial community. We therefore explored the potential of culturomics and metagenomic binning to generate a catalogue of reference genomes from the healthy human oesophageal microbiome, alongside a comparison set from saliva.Results:Twenty-two distinct colonial morphotypes from healthy oesophageal samples were genome-sequenced. These fell into twelve species clusters, eleven of which represented previously defined species. Two isolates belonged to a novel species, which we have named Rothia gullae. We performed metagenomic binning of reads generated from UK samples from this study alongside reads generated from Australian samples in a recent study. Metagenomic binning generated 136 medium or high-quality metagenome-assembled genomes (MAGs). MAGs were assigned to 56 species clusters, eight representing novel Candidatus species, which we have named Ca. Granulicatella gullae, Ca. Streptococcus gullae, Ca. Nanosynbacter quadramensis, Ca. Nanosynbacter gullae, Ca. Nanosynbacter colneyensis, Ca. Nanosynbacter norwichensis, Ca. Nanosynococcus oralis and Ca. Haemophilus gullae. Five of these novel species belong to the recently described phylum Patescibacteria . Although members of the Patescibacteria are known to inhabit the oral cavity, this is the first report of their presence in the oesophagus. Eighteen of the metagenomic species were, until recently, identified only by hard-to-remember alphanumeric placeholder designations. Here we illustrate the utility of a set of recently published arbitrary Latinate species names in providing user-friendly taxonomic labels for microbiome analyses.Our non-redundant species catalogue contained 63 species derived from cultured isolates or MAGs. Mapping revealed that these species account for around half of the sequences in the oesophageal and saliva metagenomes. Although no species was present in all oesophageal samples, 60 species occurred in at least one oesophageal metagenome from either study, with 50 identified in both cohorts.Conclusions:Recovery of genomes and discovery of new species represents an important step forward in our understanding of the oesophageal microbiome. The genes and genomes that we have released into the public domain will provide a base line for future comparative, mechanistic and intervention studies.